ANNALS  OF  ROENTGENOLOGY*  VOL'II 


THE  PATHOLOGICAL 

GALL-BLADDER 

ARIAL   W.  GEORGE,  M.D. 
RALPH  D.  LEONARD.  M.D. 


6®®®®®®®®®®®®®®®®®®®e 


Presented  by 
Francis  Leix,  D.  0. 


COLLEGE    OF    OSTEOPATHIC     PHYSICIANS 


^ 


I 

I 

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AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA      fa 
I 


THE  PATHOLOGICAL  GALL-BLADDER 


ANNALS  OF  ROENTGENOLOGY 
VOLUME  TWO 


ANNALS  OF  ROENTGENOLOGY 

A  SERIES  OF  MONOGRAPHIC  ATLASES 

EDITED  BY  JAMES  T.  CASE,  M.  D. 

Ex- President  of  The  American  Roentgen  Ray  Society 

Volumes  Published 
I.  MASTOIDS— By  Frederick  M.  Law,  M.  D.,  New  York 

II.  THE  PATHOLOGICAL  GALL-BLADDER— 

By  Arial  W.  George,  M.D.,  and  Ralph  D.  Leonard,  M.D.,  Boston 

Volumes  in  Preparation: 

III.  DIGESTIVE  DISTURBANCES  IN  INFANTS  AND  CHILDREN— 

By  Charles  G.  Kerley,  M.  D.,  and  Leon  T.  LeWald.  M.  D.,  N.  Y. 

IV.  SKULL  FRACTURES— By  William  H.  Stewart,  M.  D.,  N.  Y. 

V.  DIVERTICULA  OF  THE  ALIMENTARY  TRACT— 
By  James  T.  Case,  M.  D.,  Battle  Creek 

VI.  NASAL  ACCESSORY  SINUSES— By  Frederick  M.  Law,  M.  D„  N.  Y. 

VII.  BRAIN  TUMORS— 

By  Charles  H.  Frazier,  M.  D.,  and  Henry  K.  Pancoast,  M.  D.,  Phila. 

VIII.  THE  URINARY  TRACT— 

By  Hugh  H.  Young,  M.  D.,  and  Charles  A.  Waters,  M.  D.,  Baltimore 

Order  of  publication  and  volume  numbers  subject  to  change. 
Other  volumes  to  be  announced. 

PAUL  B.  HOEBER,  Publisher 

67-69  East  59TH  Street  New  York  City 


ANNALS  OF  ROENTGENOLOGY 

A  SERIES  OF  MONOGRAPHIC  ATLASES 

EDITED  BY  JAMES  T.  CASE,  M.D. 

Ex-President  of  The  American  Roentgen  Ray  Society 

VOLUME  TWO 


4- 


THE  PATHOLOGICAL  GALL-BLADDER 

ROENTGENOLOGICALLY   CONSIDERED   BY 

Arial  W.  George,  M.D. 

AND 

Ralph  D.  Leonard,  M.D. 


•*• 


PAUL  B.  HOEBER 

67-69  East  Fifty-ninth  Street 


NEW   YORK 


ANNALS  OF  ROENTGENOLOGY  .  VOLUME  TWO 

THE   PATHOLOGICAL 
GALL-BLADDER 

ROENTGENOLOGIC  ALLY     CONSIDERED 

ONE  HUNDRED  AND  THIRTY- FIVE  ROENTGEN  RAY  STUDIES 

ON  FORTY-FOUR  FULL  PAGE  PLATES,  THREE  OF  WHICH  ARE  PHOTOGRAPHIC 

AND  TWO  TEXT  ILLUSTRATIONS 


BY 


ARIAL  W.  GEORGE,  M.D. 

AND 

RALPH  D.  LEONARD,  A. B.,  M.D. 


BOSTON,  MASSACHUSETTS 


NEW  YORK 

PAUL  B.  HOEBER 

1922 


' 


Copyright,  1922 
By  PAUL  B.  HOEBER 


Published  January',  1922 
All  Rights  Reserved 


Printed  in  the  United  States  of  America 


DEDICATED 

TO 

DR.    PERCY    BROWN 

OUR    FRIEND    AND    COLLEAGUE 


EDITOR'S   Hvl  I  \<  I 

IT  is  tnii  much  to  expect  thai  any  man  can  be  a  specialist  in  all  ol  the 
branches  ol  medicine  in  which  roentgenology  plays  a  useful  part.  True, 
one  finds  here  and  there  an  exception  who,  because oi  a  specially  fortunate 
scries  ol  events  and  an  unusually  large  clinical  experience,  is  endowed  with 
great  usefulness  as  a  roentgenologist  w  ith  a  broad  view  point ;  hut  t  he  average 
physician  working  with  the  roentgen  rays,  even  il  he  restricts  Ins  practice 
to  the  use  of  this  newer  diagnostic  and  therapeutic  arm,  feels  keenly  his 
lack  ol  training  and  experience  m  main  ol  the  branches  ol  medicine  in  which 
his  roentgenologic  aid  is  sought.  Again  and  again  in  the  presence  of  a  case 
in  one  ol  the  less  familiar  lines,  he  will  lind  himself  longing  to  make  com- 
parison with  roentgenograms  ol  some  proven  cast'  ol  a  similar  nature,  won- 
dering what  roentgenologic  pitfalls  he  must  avoid,  lie  ma\  recall  having 
seen  some  similar  case  in  a  postgraduate  course  but  his  memorj  of  the  plate 
details  is  too  hazy  lor  reliance. 

The  scope  ol  the  roentgenologist's  judgment  is  measured  by  the  expe- 
rience he  can  kill  hack  upon.  It  is  to  supply  a  diagnostic  guide  rich  in  the 
fruit  of  experience  of  leading  authorities  in  special  fields  of  .v-ra\  that  the 
Editor  and  the  Publisher  have  conceived  the  production  of  this  series  ol 
monographic  atlases,  to  bring  to  the  roentgenologist  at  homea  postgraduate 
course  from  the  very  men  whom  he  would  seek  in  personal  \isit,  and  to 
leave  with  him  an  invaluable  series  ol  master  roentgenograms  which  he 
may  Study  and  with  which  he  may  make  comparisons  as  often  as  desired. 
Battli    Creek,  Michigan.  JAMES     I.    CASE. 


i\ 


22923 


PREFACE 

IT  was  with  a  great  deal  ol  trepidation  thai  we  attempted  to  compile  the 
materia]  that  is  presented  in  this  monograph,  realizing  the  manj  prob- 
lems involved  in  the  study  ol  the  pathological  gall-bladder.  But  we 
felt  by  presenting,  in  our  own  way,  the  problems  which  have  come  to 
us  in  the  [study  of  this  subject,  that  perhaps  it  would  become  simpler  for 
others  who  wish  to  take-  up  this  work. 

The  importance  of  the  studj  of  the  pathological  gall-bladder  l>\  the 
x-ray  is  so  great  that  this  alone  must  be  our  apology  for  offering  these  facts. 
All  our  colleagues  who  have  attempted  to  carry  on  this  work  realize  with 
us  the  difficulty  in  trying  to  reproduce  photographically  the  more  definite 
findings  of  the  photographic  plate  or  him,  and  we  realize  better  perhaps 
than  anyone  that  the  plates  that  are  reproduced  in  this  monograph  are  not 
as  excellent  as  they  can  be  made,  but  represent  the  cases  as  we,  with  our 
facilities,  were  obliged  to  take  them. 

One  must  keep  constantly  in  mind  that  we  are  dealing  frequently 
with  almost  negligible  shadow  values.  We  have  come  to  expect  even  in  the 
most  definite  cases,  hardly  discernible  shadows  on  the  x-ray  plate  or  him, 
and  when  attempt  is  made  to  reproduce  these,  they  are,  in  a  good  many 
instances,  ol  no  value  for  this  purpose. 

The  writers  have  tried  to  approach  the  problem  from  every  angle  met 

with   in  their  experience,  giving  as  definitely   as  possible  the  ways  and 

means  by  which  they  interpret  the  plates  or  films  of  t  he  upper  right  quadrant 

and   classifying  the  many  apparently  simpler  facts  which  have  later  become 

important  in  the  diagnosis.  Purposely,  the  writers  have  tried  to  choose  for 

this   monograph   the  dillicult    plates  ol   gall-stones  and   ol    the   pathological 

xi 


PREFACE 

gall-bladder,  trying  to  cover  the  problem  in  its  most  difficult  aspect,  rather 
than  choosing  the  plates  that  show  stones  and  the  gall-bladder  without 
a  great  deal  of  effort. 

It  is  the  ambition  of  the  writers  that  this  monograph  on  the  subject 
of  the  pathological  gall-bladder  will  arouse  interest  in  those  who  have  not 
been  interested,  and  renew  the  interest  of  those  who  have  been  discouraged 
by  failures.  If  these  facts  which  are  set  forth  in  the  following  pages  accom- 
plish this,  the  writers  will  feel  amply  repaid  for  bringing  this  study  before 
their  colleagues.  It  is  hoped  that  this  work  will  be  received  in  the  same 
spirit  in  which  it  is  offered  by  the  writers,  though  they  realize  more  than 
anyone  can  that  it  will  fall  far  short  of  what  they  hoped  for,  and  what 
necessarily  the  future  must  hold  for  this  special  study. 

To  obtain  the  clinical  material  for  carrying  on  this  investigation  would 
have  been  impossible  without  the  help  of  our  medical  and  surgical  colleagues. 
It  has  been  their  untiring  interest,  in  spite  of  our  failures,  in  individual 
cases,  and  their  readiness  to  grasp  the  possibilities  of  this  study  and  not  the 
least  their  appreciation  of  the  need  of  such  assistance  that  has  made  this 
work  possible. 

The  writers  wish  to  express  their  appreciation  of  the  help  of  these 
friends. 

To  Dr.  Leo  Pariseau  we  must  express  our  heartiest  thanks  for  the  French 
translation,  and  to  Dr.  I.  Gonzalez  Martinez,  for  the  Spanish  translation; 
and  to  Mr.  Paul  B.  Hoeber,  our  publisher,  we  express  our  thanks  for  his 
untiring  interest  and  help  in  the  work. 

43  Bay  Street  Road,  A.  W.  GEORGE. 

Boston,  R.  D.  LEONARD. 

December,  1921. 


CONTENTS 

CHAPTER  PAG1 

I.       1\  I  ROD!  CI  [ON I 

II.    Technique 4 

Preparation  of  the  Patient  Films  Intensifying  Screens  rube  and  liable 
— Standard  Position  Potter-Bucky  Diaphragm  Exposure  I  Inkling  of 
the  Breath-  Number  of  Plates  or  Films    Opaque  Meal. 

III.  [nterprei  \  I  I(i\ 15 

Interpretation  of  the  Films     Direct  Evidence    Classification     Differentia) 

Diagnosis — The  Visible  Pathological  Gall-BIadder  Position  of  the  (.all- 
Bladder  Shadow — Differential  Diagnosis  [ndired  I  vidence  Deformities 
Due  to  Pressure— Second  u  \  Changes  Due  to  Adhesions  Fixation  ol 
Organs  -Spastic  Changes  in  the  Stomach— Changes  in  the  Gall-BIadder. 

IV.  Conclusions     Statistics ;  5 

Roentgen  Plates  of  Pathologicai    Gall-Bladders  Thai    May  or 
May  Not  Contain  Gall-Stones 

I.     Pathological  Gall-Bladders  Containing    Gall-Stones 

(Plates  I   XII) 37 

II.     The    Visible    Pathologic  \i     G  \i  i  -Bi  \ddi  k     i  Plates     \lll 

XXV) 89 

III.     The  Pa  lhological  Gall-Bladder  :  Indirect  Evidence  (Plates 

XXVI   XI.IVi .137 


Mil 


THE  PATHOLOGICAL  GALL-BLADDER 
roentgenological.lv  considered 


Chapter  1 
INTRODUCTION 


IT  N  [910  we  had  the  privilege  of  visiting  the  various  gastro- 
intestinal clinics  of  Europe  It  was  obvious  to  an\  observer 
who  hoped  to  make  an  accurate  studj  "I  the  lesions  oi  the 
-1  irastro-intcstinal  tract  licit  the  continental  method  of  study  was 
lacking  in  something  to  make  it  complete.  No  effort  was  being  made  to 
solve  the  gall-stone  problem,  except  ill  some  slight  experimental  way.  It 
was  openly  taught  that  gall-stones  could  not  be  demonstrated  in  a  great 
majority  of  cases. 

On  returning  to  this  country  and  seeing  the  work  of  Lewis  Gregory  Cole, 
to  whom  more  than  any  other  individual  we  are  indebted  for  the  stimulation 
to  carry  on  this  work,  we  observed  that  in  his  direct  studj  oi  the  duodenum 
by  the  plate  method,  he  was  incidentally  visualizing  gall-stones  in  a  large 
number  of  cases.  It  was  clear  that  the  reason  for  this  [ay  in  the  fact,  that 
by  perfecting  his  plate  technique  to  such  a  point  as  to  bring  out  the  slight 
changes  in  the  duodenum,  he  thereby  made  clear  the  hunt  and  obscure 
shadows  ol  any  gall-stones  which  happened  to  be  present.  Hence,  when  we 
took  the  opportunity  to  study  ulcer  of  the  duodenum  by  our  modification  <>t 
Cole's  method,  we  also  began  to  see  gall-stones  w  ith  increasing  frequency.  At 
once  our  interest  became  centered  on  the  gall-stone  problem.  We  became 
ambitious  to  show  as  many  Stones  as  possible,  and  became  curious  as  to 
what   percentage  of  all  gall-stones  could   be  demonstrated.  We  made  sc\cral 

attempts  at  a  statistical  study.  While  realizing  a1  the  time  how  figures  lie 
and  that  such  studies  were  almost  valueless,  >  et  we  hoped,  b\  presenting 
these  statistics,  to  arouse  in  other  roentgenologists  an  active  interest   in  this 


2  THE  PATHOLOGICAL  GALL-BLADDER 

problem.  We  expected,  by  stimulating  a  universal  study  of  the  right 
upper  quadrant,  to  arrive,  as  time  went  on,  at  a  higher  percentage  of 
correct  diagnoses. 

This  work  was  carried  on  until  1917.  At  this  time  we  began  to  realize 
that  there  was  a  certain,  and  possibly  a  large  percentage  of  cases  actually 
having  gall-stones,  in  which  the  character  of  the  gall-stones  was  such  that 
it  was  almost  a  physical  impossibility  to  visualize  the  stones  on  the  photo- 
graphic plate.  We  were,  therefore,  forced  to  seek  other  evidence,  besides  the 
mere  demonstration  of  stones,  whereby  a  diagnosis  of  diseased  gall-bladder 
could  be  established.  Our  attention  was  called  in  certain  cases  to  a  shadow 
in  the  right  upper  quadrant,  having  the  size,  shape,  and  position  of  the  gall- 
bladder. This  shadow,  we  inferred,  represented  a  gall-bladder  full  of  stones, 
no  single  stone  being  of  sufficient  density  to  cast  a  shadow. 

Occasionally,  a  patient  showing  this  shadow  would  be  found  at  operation 
to  have  only  a  chronically  inflamed  gall-bladder  without  any  stones.  We 
then  appreciated  for  the  first  time  that  the  pathological  gall-bladder  might, 
under  certain  conditions,  cast  a  shadow,  even  when  no  stones  were  present. 
Our  observation  as  to  the  demonstration  of  the  pathological  gall-bladder  we 
have  considered  the  greatest  step  in  advance  toward  the  solution  of  the 
gall-bladder  problem.  Since  191  ~  the  emphasis  in  our  work  has  been  placed 
on  the  visualization  of  the  pathological  gall-bladder  and  the  demonstration 
of  the  results  of  gall-bladder  disease  on  the  surrounding  organs. 

In  the  earlier  study  of  gall-stones  by  the  use  of  the  x-ray,  one  should 
not  overlook  the  early  demonstration  of  gall-stones  by  Beck  of  New  York 
and  Thurstan  Holland  of  England.  There  have  been  a  few  roentgenologists 
who  have  from  time  to  time  emphasized  the  study  of  gall-stones  by  the 
roentgen  method.  Principally,  among  these  investigators  have  been  Cole  of 
New  York,  Case  of  Battle  Creek  and  Pfahler  of  Philadelphia,  who  have  been 
of  help  to  us  personally  in  carrying  on  this  work.     Dudley  Roberts  of  New 


THE  PATHOLOGICAL  GA1  I  -Bl  UDDER 

York  in  the  last  few  years  has  made  a  definite  studj  oi  the  pathological 
gall-bladder  and  gall-stones.  Knox  ol  England  has  |>ecn  a  meat  stimulus  to 
all  to  continue  this  work.  His  experimental  work  on  the  varying  densities 
and  types  oi  gall-stones  should  be  studied  caret u lb  by  all  those  who  an 
interested  in  these  problems.  It  is  because  ol  our  appreciation  of  his  work 
that  we  have  omitted  any  consideration  along  these  lines  in  this  monograph, 
as  it  would  be  impossible  to  improve  at  the  present  time  upon  what  Knox 
has  already  pul  dished. 

Our  work  would  have  been  much  simpler  il  more  ol  our  colleagues  had 
taken  it  up  and  given  us  t  he  bench  t  ol  their  obserx  at  ions;  but  there  has  been 
SO  little  published  upon  this  particular  aspect  of  the  stud\  of  the-  biliar\ 
tract  that  it  has  required  a  good  deal  ol  time  on  our  part  to  accumulate  facts 
and  observations  which  would  be  ol  value.  Considerable  material  has  been 
published  in  the  last  ten  years  upon  the  experimental  study  of  gall-stones, 
most  ot  which  has  been  studied  outside  the  bodj  or  b\  placing  the  stones  in 
different  media,  such  as  water,  wood,  paper  and  beef;  and  it  has  been  the 
opinion  of  the  writers  that  there  has  been  no  definite  analogy  between  the 
experimental  study  ol  gall-stones  in  this  way  as  compared  with  the  study  of 
gall-stones  in  the  living.  It  would  have  been  a  very  discouraging  problem 
it  the  facts  which  have  been  deducted  from  the  experimental  studj  of  gall- 
stones were  criteria  of  what  we  should  find  in  the  living. 


Chapter  II 
TECHNIQUE 

THERE  is  nothing  mysterious  or  complicated  in  the  technique  of  roent- 
genographing  a  patient  for  gall-bladder  disease.  The  simplest  way  is 
always  the  best  way;  hence,  we  have  discarded  in  our  method  of  procedure 
anything  which  has  seemed  an  unnecessary  complication. 

Preparation  of  the  Patient 

As  most  of  our  gall-bladder  examinations  are  made  in  conjunction  with 
a  general  gastro-intestinal  study,  we  allow  nothing  to  be  done  in  the  way  of 
preparation  which  would  interfere  with  the  study  of  the  stomach  or  intes- 
tines. This  rules  out  any  violent  purgation  because  of  its  effect  on  the  motility 
of  the  intestinal  tract,  it  being  our  endeavor  to  study  patients  in  their  usual 
habits  of  living.  A  cleansing  enema,  however,  is  desirable,  in  that  it  thor- 
oughly cleans  out  the  hepatic  flexure  area  of  the  colon  in  the  region  of  the 
gall-bladder,  while  not  interfering  with  the  subsequent  intestinal  motility. 

More  important  is  the  requirement  that  the  patient  present  himself 
for  examination  with  an  empty  stomach.  As  our  patients  come  in  the 
morning,  we  recommend  that  they  omit  the  breakfast.  If  this  seems  too  much 
of  a  hardship,  a  little  liquid  such  as  tea,  coffee,  milk  or  bouillon  may  be  taken 
at  least  two  hours  previous  to  the  examination.  This  will  obviate  any  tendency 
to  faintness,  particularly  when  the  patient  comes  to  the  office  from  some 
distance.  We  are  particular  about  the  stomach  being  empty,  for  a  food-filled 
antrum  or  duodenum  may  produce  shadows  simulating  the  gall-bladder  or 
gall-stones. 

It  goes  without  saying,  that  all  drugs  should  be  omitted  for  at  least 
two  days  previous  to  the  examination.  This  is  particularly  true  of  medicine 
containing  bismuth.  It  is  surprising  how  long  bismuth  may  adhere  to  the 


HIE  PATHOLOGICAL  GALL-HI  ADDER 

intestinal  walls  and  it  in  the  hepatic  flexure  region  maj  produce  confusing 
shadows  in  the  right  upper  quadrant.  \\  hen  all  is  said  and  done,  il  shadows 
appear  on  t  lie  him  which  are  suspicious  but  indefinite,  one  should  not  hesitate 
tn  repeal  the  examination  on  another  day. 

I'll  MS 

The  ,\-ra\  evidence.'  of  gall-bladder  disease  is  of  such  a  character  as  to 
require  the  use ol  films  or  plates  for  its  demonstration.  Our  earlier  work  was 
done,  ol  course,  entirely  with  glass  plates.  I  he  advent  ol  the  duplitized  him 
about  three  years  ago  entirely  superseded  the  use  ol  plates  in  our  office, 
since  which  time  we  have  found  no  disadvantage  in  their  use  either  for  gall- 
bladder or  genera]  \-ra\    work. 

In  this  connection,  it  ma\  be  said  that  throughout  the  text  the 
words  "plate"  and  "him"  are  used  almost  synonymously.  Fluoros- 
copy has  been  of  no  practical  value  in  this  line  of  work;  in  fact,  in 
some  ways  it  has  seemed  an  actual  detriment  to  the  perfection  ol  gall- 
bladder diagnosis.  Except  by  remote,  indirect  methods,  there  is  nothing 
within  the  power  of  the  fluoroscope  to  give  the  least  information 
regarding  the  pathological  gall-bladder.  If  all  observers  in  this  country 
had  used  the  lluoroscope  exclusively,  a  demonstration  ol  gall-stones  would 
have  been  the  rarest  observation,  and  the  visualization  of  the  gall-bladder 
unknown.  Some  ol  our  colleagues  who  have  had  the  best  opportunities  tor 
studying  large  numbers  of  gastro-mtcst  mal  cases,  have  been  of  the  hast 
assistance  in  the  solution  ol  this  problem,  because  their  observations  were' 
confined  mainlj  to  the  fluoroscope. 

Intensifying  Screens 
From  the  very  beginning,  the  intensifying  screen  has  been  the  founda- 
tion for  our  gall-bladder  work.  Without  its  use  but  little  progress  would  have 
been  made.  It  was  found  to  be  essential  in  obtaining  that  additional  bit  ol 


6  THE  PATHOLOGICAL  GALL-BLADDER 

contrast  so  necessary  to  bring  out  the  slight  variations  in  the  density  of  the 
gall-stones. 

It  is  just  at  this  point  that  many  men  have  failed  to  achieve  gratifying 
results.  The  difference  in  density  between  a  gall-stone  or  gall-bladder  and  the 
surrounding  tissue  is  so  slight  that  it  is  frequently  not  detected  on  a  straight 
plate  or  film,  but  may  become  visible  when  the  intensifying  screen  is  used. 
Those  who  persist  in  using  straight  films  or  plates  (without  the  intensifying 
screen)  will  overlook  a  large  percentage  of  gall-stones  and  pathological 
gall-bladders. 

For  years  we  have  used  the  single  screen  and  plate  and  have  continually 
been  bothered  by  the  grain  of  the  screen  which  seems  to  be  accentuated  in 
the  plate.  Furthermore,  any  defect  in  the  screen  is  clearly  reproduced  on  the 
plate,  and  many  of  these  defects  produce  shadows  simulating  gall-stones. 
We  attempted  to  eliminate  these  sources  of  error  by  using  in  each  case  a 
series  of  screens,  so  that  before  stating  that  gall-stones  were  present,  the 
same  shadows  must  be  obtained  throughout  the  series  of  plates. 

With  the  development  of  the  "double  intensifying"  screen  and  dupli- 
tized  film,  the  sources  of  error  from  screen  grain  and  defects  are  practically 
done  away  with.  The  defects  of  one  screen  are  apparently  offset  by  the 
good  screen  on  the  other  side  of  the  film.  We  feel  today  that  not  only  is  a 
screen  necessary  for  gall-bladder  work,  but  the  best  work  requires  a  double 
screen  used  with  a  duplitized  film.  The  double  screen  seems  to  increase 
twofold  the  advantages  of  the  single  screen  and  proportionately  to  diminish 
its  faults. 

Tube  and  Table 

Experience  has  shown  us  that  uniformly  better  results  are  obtained 
while  using  some  type  of  Coolidge  tube.  The  right  degree  of  penetration, 
being  of  fundamental  importance,  can  always  be  obtained  with  this  tube. 
It  is  true  that  occasionally  a  very  brilliant  plate  is  obtained  with  the  gas 


THE  PATHOLOGICAL  GALL-B1  ADDER 

tube,  but  on  account  of  the  uncertainty  of  the  vacuum  the  duplication  oi 
excellent  plates  is  difficult. 

Other  things  being  equal,  the  finer  the  focus  the  better  the  detail.  As 
our  technique  requires  a  rather  high  milhamperage  a  too-line  focus  tube  ma\ 
heat  up.  For  general  routine  work  the  medium  focus  Coohdge  tube  has 
proved  satisfactory,  as  well  as  the  hue  Incus  radiator  type. 

No  speeial  form  of  tube-stand  is  required.  We  prefer  a  small  cone  and 
diaphragm.  The  cone  which  we  routinely  use  measures  5 '  .  inches  in  length, 
with  a  31  -j- inch  diaphragm.  1  he  same  is  true  ol  a  table.  As  no  unusual  posi- 
tion of  the  patient  is  necessary,  an  ordinarj  horizontal  table  answers  all 
purposes.  In  our  office  wooden  tables  are  used,  which  incidentally  do  awaj 
with  any  static  discharge. 

Si  \\d  \kd   Posn  n>\ 

We  use  a  standard  position.  All  cases  are  taken  prone,  the  patient 
lying  on  the  screen  with  the  tube  above.  The  screen  is  placed  beneath  the 
right  upper  quadrant  so  that   it  is  bisected  by  the  right  costal  margin. 

The  most  practical  sized  screen  to  use  is  the  8-  by  1 0-inch.  It  is  possible 
to  use  a  61  j-  by  S1  .-inch  or  possibb  a  smaller  one,  but  in  using  a  screen  that 
is  too  small  one  ma\  overlook  a  gall-bladder  it  it  is  m  an  abnormal  position. 

The  tube  is  placed  above,  the  central  ray  perpendicular  to  the  plate, 
using  the  smallest  circle  and  cone  which  at  a  given  distance  will  cover  the 
plate.  This  is  centered  midwaj  over  the  costal  margin  so  that  the  exposure 
will  give  as  much  area  above  the  costal  margin  as  below   it  (Figs.   I  and  2). 

The  distance  ol  the  tube  from  the  1 1 1 111  and  screen  varies.  I  sing  a 
medium-locus  tube,  distance  becomes  ol  importance  in  bringing  out  sharp- 
ness of  detail.  \\  ith  a  line-locus  tube,  distance  is  ol  less  importance  so  far  as 
detail  is  concerned;  this  also  is  the  ease  for  the  radiator-type  tube.  The 
following  rule  holds  true  in  gall-stone  work  just  as  in  other  \-ra\  work.  II  the 


8 


THE  PATHOLOGICAL  GALL-BLADDER 


object  being  roentgenographed  is  an  appreciable  distance  from  the  film,  the 
tube  must  be  a  correspondingly  greater  distance  away  in  order  not  to  produce 
a  distorted  shadow.  For  instance,  in  a  stout  individual,  where  there  may  be 
several  inches  of  abdominal  fat  between  the  gall-stone  and  the  film,  the 


Fig.   i. 


tube  should  be  quite  a  distance  away  in  order  not  to  destroy  the  shadow 
by  the  divergence  of  the  rays.  Under  ordinary  circumstances,  the  tube 
should  not  be  tilted  or  the  angle  changed.  We  are  endeavoring  to  demon- 
strate a  shadow  as  being  constant  in  a  series  of  films.  If,  now,  the  angle  at 


THE  PATH01  OGICA]    GA1  I  -Bl  M)l)l  R 


which  the  films  are  taken  is  changed,  we  thereby  introduce  a  new  variable 
factor  which  will  cause  a  variation  in  the  shadows  on  the  film.  1 1  \\  e  observ  e 
on  any  one  him  a  shadow  which  is  suggesth  e  oi  gall-bladder  disease,  we  en- 
deavor to  visualize  this  shadow  more  clearlj  1>\  changing  the  penetration 
and  time  oi  exposure,  and  not  In  changing  the  angle  oi  the  tube. 


Fig.  2. 
However,  it  max  occasionally   be  necessary  to  change  the  angle  of  the 

tube    in    east's    where    apparent    gall-stone    shadows    lie    within  the  shadow 

produced  In  the  spine.  I  his  condition  ma\  occur  where  there  is  a  scoliosis, 
particularly  with  the  curve  toward  the  right.  Postoperative  eases  may  also 
present  tins  condition  as  a  result  oi  adhesions. 

Too  much  emphasis  cannot  be  laid  on  this  point  of  placing  the  tube  so 
as  to  cover  the  area  wanted  and  keeping  it  there,  varying  the  technique 
only  as  may  be  required  to  improve  the  quality  of  the  film.  The  patient  must 


io  THE  PATHOLOGICAL  GALL-BLADDER 

be  instructed  to  lie  in  one  position  (prone)  and  maintain  that  position 
throughout  the  entire  examination.  He  should  turn  the  head  only  from  side 
to  side,  rather  than  turn  the  body  to  make  his  position  more  comfortable. 
It  sometimes  seems  advisable  to  change  the  screens  under  the  patient 
by  using  a  funnel  or  by  putting  them  beneath  the  table,  so  as  not  to  disturb 
the  position  of  the  patient.  The  disadvantage  of  this  technique  is  that  it  is 
necessary  to  place  the  screen  as  close  as  possible  to  the  patient.  Every 
additional  fraction  of  an  inch  that  is  interposed  between  the  anterior 
abdominal  wall  of  the  patient  and  the  intensifying  screen  adds  to  our 
difficulty  by  destroying  detail. 

POTTER-BuCKY    DlAPHRAGM 

The  use  of  the  Potter-Buckey  diaphragm  has  materially  helped  in  the 
study  of  all  portions  of  the  body  to  which  it  is  applicable,  and  it  has  seemed 
from  our  experience  that  it  should  be  of  distinct  advantage  in  the  study  of  the 
right  upper  quadrant.  This  is  particularly  true  in  the  muscular  and  well- 
nourished  individuals.  Unquestionably,  when  one  understands  the  technique 
of  the  movable  grid,  more  detail  is  brought  out  of  the  soft  parts  than  without 
its  use,  especially  in  making  visible  the  kidney,  for  example.  The  study  of  the 
visible  gall-bladder  also  is  simplified  to  a  certain  extent  by  its  use,  but  one 
must  understand  the  use  of  the  grid  and  also  realize  that  there  is  a  certain 
amount  of  distortion  that  naturally  comes  from  the  use  of  this  apparatus. 
Gall-stones  which  are  difficult  to  make  visible  under  ordinary  routine  tech- 
nique, if  care  is  used  will  stand  out  more  brilliantly  and  with  more  contrast 
with  the  use  of  the  grid.  Its  greatest  help  to  us  individually  has  been  in  the 
differentiation  between  gall-stones  and  renal  stones,  especially  when  using 
the  lateral  position.  Shadows  due  to  calcium  which  may  or  may  not  be  gall- 
stones and  with  the  ordinary  technique  would  be  difficult  to  make  visible 
in  the  lateral  view,  seem  to  be  clearer  and  more  easily  discernible  when  using 
the  diaphragm. 


Tin:  iwtiioi  ()(,ic\i  cam  -i'.i  \i)Di  u 

We  have  not  attempted  to  hm'  the  Potter-Buckej  diaphragm  routinely 
m  the  normal  or  the  average-sized  person.  I  he  distance  between  the  Mini  and 
the  patient's  abdominal  wall  and  the  necessarily  slightlj  longer  exposure 
required,  are  disturbing  factors  in  obtaining  the  most  satisfactorj  plati 
It  is  hoped  that  as  we  gain  more  experience  in  the  use  oi  the  Potter-Buckej 
diaphragm  in  thestudj  of  gall-bladder  disease,  we  maj  find  its  use  of  increa  - 
ing  \  alue. 

PNE  l  MOPER]  K)\l  I  \1 

It  has  not  been  our  privilege  to  utilize  the  pneumoperitoneal  injections 
lor  the  study  oi  the  biliary  tract.  We  have  realized  that  it  is  possible  to 
make  clearly  visible  all  gall-bladders,  almost  without  exception,  with  the  gas 
injection  method;  and  undoubtedly  stones  which  under  ordinary  circum- 
stances would  not  be  visible  in  the  roentgen  plate,  can  at  least  be  suspected 
with  the  injection  method.  Its  routine  use  lor  the  studj  ol  the  gall-bladder 
lias  not  been  attempted  by  us.  It  is  onI\  m  the  studj  lor  other  conditions 
that  occasionally  we  meet  with  conditions  ol  the  gall-bladder  not  suspected 
clinically  <>r  possibly  not  seen  m  a  previous  roentgen  examination. 

It  is  imt  the  wish  ol  the  writers  to  deprecate  the  value  ol  this  method, 
but  more  to  urge  that  the  ordinary  methods  be  better  developed  before  one 
considers  this  new  method,  solely  lor  the  purpose  ol  studying  the  biliary 
tract.  I  ndoubtedly  one  will  meet  with  cases  in  this  study  which  would  make 
the  use  ol  the  pneumoperitoneum  imperative,  but  the  large  majority  ol  these 
cases  that  cannot  be  settled  either  by  accepted  clinical  methods  or  by  care- 
ful roentgen  study  would   necessarily  seem  to  indicate  surgical  exploration. 

ExPOSt  hi 

The  correct  degree  ol  penetration  is  ol  the  utmost  importance  in  pro- 
ducing the  ideal  gall-bladder  him.  Individuals  vary  so  greatlj  that  no 
fixed  exposure  rule  can  be  given;  suffice  it  to  say,  that  in  a  given  case  that 


ia  THE  PATHOLOGICAL  GALL-BLADDER 

degree  of  penetration  should  be  used  which  will  just  pass  through  the  patient. 
In  other  words,  use  the  "softest"  possible  ray  that  will  penetrate  to  the 
film.  For  some  patients  a  219-inch  spark  gap  might  be  sufficient,  while  for 
stouter  individuals  31 2  to  4^  inches  may  be  necessary.  It  should  always 
be  borne  in  mind  that  we  are  dealing  with  very  slight  variations  in  density, 
so  that  the  slightest  degree  of  over-penetration  may  obliterate  many  of  these 
faint  shadows. 

The  length  of  exposure  requires  attention  as  well  as  the  degree  of 
penetration.  The  exposure  time  should  not  be  unduly  prolonged — a  second 
and  a  half  at  the  longest.  Too  prolonged  an  exposure  gives  opportunity  for 
motion  on  the  part  of  the  patient.  Movement  caused  by  respiration,  muscle 
tremor,  or  even  arterial  pulsation  might  be  enough  to  obliterate  the  shadows 
of  gall-stones  or  of  the  gall-bladder. 

Holding  of  the  Breath 

An  important  factor,  therefore,  in  exposing  the  plate  is  the  correct 
holding  of  the  patient's  breath.  While  this  would  seem  to  be  a  simple  matter, 
yet  it  is  one  of  the  most  difficult  things  in  which  to  instruct  patients  and 
have  them  carry  out  accurately.  A  plate  or  film  perfectly  exposed  as  to  time 
and  penetration,  becomes  valueless  if  there  is  the  slightest  motion  on  the 
part  of  the  patient.  We  take  a  good  deal  of  time  in  explaining  to  patients 
how  to  hold  their  breath.  We  do  not  attempt  to  have  them  hold  it  after  a 
deep  inspiration,  for  we  have  found  that  they  are  gradually  expelling  the  air 
during  the  exposure.  We,  therefore,  instruct  them  to  stop  breathing  the 
instant  we  give  the  signal,  attempting  neither  to  inspire  nor  expire.  This, 
for  the  moment,  gives  them  no  desire  to  inhale  or  exhale,  and  during  that 
brief  interval  the  exposure  is  made.  We  cannot  emphasize  too  strongly 
the  importance  of  a  correct  holding  of  the  breath,  for  we  have  observed  that 
a  large  number  of  our  failures  in  diagnosis  have  been  due  to  motion  at  the 
time  of  exposure. 


THE  PATHOLOGICAL  GALL-BLADDER  13 

Number  oi    Plates  or   Films 

One  should  not  limit  oneseli  to  an\  fixed  number  oi  plates  or  films. 
Each  patient  is  a  rule  unto  himself.  Repeated  films  must  be  made  until  a 
satisfactory  degree  ol  detail  is  obtained.  For  some  patients  two  or  thre< 
exposures  maj  be  sufficient,  others  maj  require  ten,  a  dozen,  or  even  more. 

Our  routine  is  to  make  one  exposure,  estimating  the  time  and  pen*  na- 
tion best  suited  for  the  type  oi  patient.  I  his  him  is  then  developed  under 
the  personal  supervision  oi  the  operator,  who  determines  whether  a  ch; 
should  be  made  m  the  next  exposure  to  produce  a  more  satis  factor  J  him. 
In  laet,  each  him  is  developed  and  examined  before  the  next  one  is  taken. 
We  have  found  it  a  waste  ol  time  and  energy  to  take  lour  or  five  films  at  a 
time  and  have  them  all  developed  at  once.  1  his  process  of  alternately 
exposing  and  developing  is  continued  until  the  operator  is  conhdent  that 
the  best  detail  possible  lor  that  particular  patient  has  been  obtained. 

A  satisfactory  gall-bladder  him  should  show  at  least  the  twelfth  and 
eleventh  ribs  and  the  lower  dorsal  and  upper  lumbar  vertebrae  (Plate  XIV, 
big.  43).  On  account  ol  the  lack  ol  penetration,  spine  detail  is  usually  not 
obtained.  The  transverse  processes,  however,  should  be  clearly  seen.  The 
lower  edge  and  the  lower  portion  ol  the  outer  edge  of  the  li\er  should  be 
visible.  A  portion  ol  the  right  kidney  should  also  be  seen  on  a  satisfactory 
him.  I  he  kidney  shadow  will  be  somewhat  enlarged  bom  distortion,  since 
the  exposure  is  made  w  it  h  the  hi  m  on  the  anterior  abdominal  wall.  Occasion- 
ally, however,  the  kidney  shadow  is  not  seen  on  the  film.  This  may  be 
due  to  the  laet  oi  Us  occupying  an  unusually  low  position  or  from  some 
unknown  cause.  When  the  kidney  shadow  is  visible,  it  simplifies  the  inter- 
pretation ol  the  film.  W  hen  the  source  ol  a  suspicious  shadow  on  thi'  film  is 
being  considered,  the  kidney  being  definitely  identified  is  thus  eliminated 
as  a  possible  cause. 


i4  THE  PATHOLOGICAL  GALL-BLADDER 

Opaque  Meal 
Finally,  after  obtaining  a  sufficient  number  of  gall-bladder  films,  the 
patient  is  given  a  barium  meal.  Films  or  possibly  the  fluoroscopic  examina- 
tion after  such  a  meal  may  reveal  any  of  the  secondary  or  indirect  evidence 
pointing  to  gall-bladder  disease.  The  meal  consists  of  500  c.c.  of  buttermilk 
to  which  has  been  added  80  gm.  of  the  specially  prepared  barium  sulphate. 
Any  other  of  the  accepted  media  could  be  used.  We  have  used  buttermilk 
for  the  past  ten  years;  all  our  observations  have  been  made  with  this  meal, 
and  as  yet  we  have  found  no  reason  to  make  a  change. 


Chapter  111 

INTERPRETATION 
Km  rpr]  i  \  i  io\  in    i  in    Films 

HAVING  obtained  lilms  as  near  technically  perfect  as  possible,  the 
next  problem  is  to  interpret  the  evidence  winch  these  lilms  present. 
\\  luK'  there  is  greal  room  for  improvement  in  our  technique,  there  is  still 
greater  opportunity  for  perfecting  our  interpretations,  rhere  is  more  in  the 
dims  today  than  we  can  read.  Only  In  continuous  study  ol  the  \-ra\ 
evidence  and  checking  up  after  operation  or  autopsj  can  progress  be  made. 
It  must  be  borne  in  mind  that  todaj  the  roentgenologist  is  not  interested 
simply  m  the  demonstration  ol  gall-stones,  but  in  the  broader  held  ol  gall- 
bladder disease.  We,  therefore,  study  the  films  for  other  evidences  of  gall- 
bladder disease,  besides  the  mere  visualization  oi  stones. 

Direct  Eviden(  i 
For  our  convenience  in  teaching,  we  have  divided  the  x-ray  evidence 

ol  a  pathological  gall-bladder  into  two  general  groups:  direct  and  indirect. 
Under  direct  evidence  let  us  consider,  first,  the  demonstration  oj  gall-stones. 
Stones  will  show  on  the  plate  il  there  is  sufficient  difference  m  density  between 
the  stone  or  group  ol  stones  and  the  surrounding  tissue.  Il  is  only  this  differ- 
enct  in  density  which  the  x-ray  detects  and  nothing  man.  In  general,  the  more 
lime  salts  a  stone  contains,  the  greater  its  density  and  the  more  casik 
demonstrated.  Unfortunately,  the  ordinary  stone  contains  onl\  a  small 
amount  ol  calcium,  the  bulk  ol  the  stone  being  composed  ol  cholcstcrin  and 
bile  pigment.  \\  e  roughk  classify  gall-stones  according  to  their  X-ray 
appearance. 

Visible  Gall-Stones.  The  majority  ol  gall-stones  visualized  on  the 
x-ray  him  present  the  so-called  peripheral  shadow  (Plate  III,  Fig.  9). 
The  stone  appears  as  a  ring.  This  appearance  may  be  explained  by  the  fact 


16  THE  PATHOLOGICAL  GALL-BLADDER 

that  the  periphery  contains  more  lime  than  the  central  portion;  on  the  other 
hand,  any  more  or  less  translucent  spherical  body  when  viewed  by  trans- 
mitted light  will  present  this  "ring"  appearance. 

Laminated  stones  may  be  found  (Plate  X,  Figs.  30  and  31).  Their 
shadows  are  similar  to  the  cross  section  of  a  tree-trunk  where  the  growth  rings 
are  visible.  This  peculiar  picture  is  undoubtedly  due  to  different  layers  of 
salts  being  gradually  deposited  on  the  surface  of  the  stone  from  time  to  time, 
some  of  the  layers  containing  more  calcium  than  others. 

Dense  homogeneous  shadows  are  occasionally  seen  (Plate  V,  Fig.  15). 
This  type  of  shadow  represents  a  stone  containing  much  calcium  evenly 
distributed  throughout.  Such  a  stone  may  resemble  a  kidney  stone  and 
therefore  requires  more  care  in  the  differential  study. 

Fairly  dense  shadows  may  be  found  which  suggest  a  mass  of  small 
stones  or  a  collection  of  "sand,"  rather  than  one  large  solitary  stone.  In- 
spissated bile  may  at  times  be  dense  enough  to  cast  a  shadow  on  the  plate 
(Plate  VIII,  Fig.  23). 

Experimentally,  the  so-called  "negative"  stones  may  be  demonstrated. 
These  stones  are  of  less  density  than  the  surrounding  tissue  and  appear  on  the 
film  as  dark  areas  (being  more  easily  penetrated  by  the  x-ray).  While 
theoretically  such  stones  can  be  demonstrated  in  a  patient,  practically  it  is 
a  rare  occurrence.  Such  shadows,  when  seen,  must  be  differentiated  from 
small  collections  of  gas  in  the  stomach  or  intestine. 

Stones  may  vary  in  number  from  one  up  to  hundreds.  Some  of  the  single 
stones  may  grow  to  a  large  size.  The  whole  gall-bladder  may  be  filled  with 
one  large  stone.  Some  of  these  large  stones  measure  3  inches  or  so  in  the 
longest  diameter.  All  gradations  in  size  are  found,  down  to  collections  of 
minute  specks,  which  are  commonly  called  "sand." 

We  do  not  find  the  great  variety  in  the  shape  of  gall-stones  that  is  seen 
in  kidney  stones.  In  general,  gall-stones  are  not  extremely  irregular,  being 


I  111     PATHOLOGICAL  GALL-BLADDER 

usually  rounded.  When  several  stones  are  present,  thej  become  faceted 
and  produce  a  polygonal  shadow,  frequently  triangular  (Plate  \lll. 
Fie.  26). 


'6 


Ci  vssu  u  \  1  io\ 

With  the  permission  of  the  author,  we  have  adapted  the  classification 
of  gall-stones  as  devised  In  Dr.  Dudley  Roberts.  This  classification  we 
consider  one  of  the  most  practical  up  to  the  present  time;  at  least  from  an 
x-ray  viewpoint. 

1.  The  Radial  Cholesterin  Stone.  This  rare  type  of  single  stone  occurs  in  gall- 
bladders which  show  evidence  of  dilatation  without  inflammation.  It--  structure  is 
peculiar,  in  that  it  is  composed  of  pure  cholesterin  crystals  that  radiate  from  the 
center  to  the  surface.  This  stone  is  less  dense  than  all  surrounding  tissue,  and  can 
be  visualized  only  as  a  negative  shadow,  that  is,  a  round  or  oval  dark  spot. 

2.  The  Combination  Stone.  When  inflammation  develops  in  a  gall-bladder 
which  contains  a  radial  cholesterin  stone,  the  inflammatory  exudate  causes  a 
deposit  of  lime  salts  on  the  stone,  and  this  layer  shows  as  a  ring  or  oval  shallow. 
It  sometimes  happens  that  the  lime  is  unequally  deposited  and  onlj  a  segment  is 
visualized. 

3.  Cholesterin-Bilirubin  Calcium  Stones.  This  rather  common  type  is  fairly 
large,  from  two  to  live  in  number,  frequently  faceted  and  nested  in  the  neck  ot  the 
<iall-bladder  or  the  cystic  duct.  The\  are  usualh  not  layered,  and  the  calcium  salts 
are  equally  distributed  through  the  mass  of  the  stones  so  that  thej  do  not  show  as 
rings  or  triangles  but  as  solid  spots  or  as  an  elongated  finger-like  dense  area  due  to 
the  nesting  of  the  stones.  The  percentage  of  lime  is  \  erj  small,  and  the  shadows  are 
lost  by  the  slightest  movement  or  over-penetration  or  darkening  01     bodj  rays. 

4.  Common  Multiple  Faceted  Stones.  As  this  group  represents  nearlj  hall  ot 
all  stones,  familiarity  w ith  their  size,  si ructure  and  roentgenographs  characteristics 

is  most  important.  Their  number  is  usually  great,  seldom  less  than  twenty,  fre- 
quently several  hundreds.  They  are  usually  small,  faceted,  and  very  irregular  in 
shape.  They  are  composed  of  cholesterin  and  bile  salts  with  very  little  intermixed 


1 8  THE  PATHOLOGICAL  GALL-BLADDER 

lime,  but  with  a  thin  coating  on  some  facets  of  some  of  the  stones  in  a  considerable 
percentage  of  collections.  The  visualization  of  some  of  these  stones  is  exceedingly 
easy  because  of  the  dense  lime  coating  which  gives  rise  to  an  irregular  mosaic.  The 
greatest  detail  is  necessary  to  visualize  the  majority,  and  one  must  learn  to  recognize 
the  faint  mosaic  of  the  gall-bladder  filled  with  such  stones.  This  mosaic  or  spotted 
appearance  is  due  either  to  the  slight  coating  of  stones  with  lime  salts  or  to  negative 
shadows  made  by  the  readily  penetrated  stones  outlined  by  the  denser  bile.  When 
the  gall-bladder  is  crowded  with  relatively  soft  stones,  the  mass  is  sometimes  suffi- 
cient to  cast  a  definite  shadow  of  a  gall-bladder  in  which  no  individual  shadows  can 
be  seen.  These  negative  shadows  are  hard  to  interpret  as  stones  because  their  outline 
is  diffuse.  No  matter  how  great  the  detail  is  which  we  are  ultimately  able  to  obtain 
in  this  work,  fully  15  per  cent  of  stone  diagnoses  must  be  made  by  recognition  of 
this  persistent  spotty  appearance  made  by  those  soft  stones  in  the  fluid  gall-bladder 
contents.  At  present  it  is  impossible  to  secure  evidence  of  this  type  of  stones  in 
heavy  subjects,  and  allowance  must  always  be  made  for  this  fact  in  making  negative 
diagnoses. 

5.  Pure  Bilirubin  Lime  Stones.  These  occur  either  as  small  seed-sized,  soft 
black  granules,  or  as  several  larger  stones.  While  they  are  extremely  soft  and  friable, 
they  contain  a  definite  admixture  of  lime,  and  only  their  small  size  makes  their 
recognition  difficult. 

6.  Calcium  Bilirubinate  Stone.  This  stone  is  usually  single  and  of  flinty  hard- 
ness throughout,  and  consequently  it  gives  rise  to  solid,  unmistakables  hadows. 
It  unfortunate!  v  represents  only  about  5  per  cent  of  all  gall-stones. 

Differential  Diagnosis 

In  the  differential  diagnosis  of  gall-stones,  the  shadows  of  calcified 
costal  cartilages  require  consideration.  Cases  where  the  entire  cartilage 
is  calcified  offer  no  particular  difficulty;  but  in  some  cases  the  cartilage  is 
only  partly  calcified  and  there  may  be  some  discrete  areas  of  lime  salts 
deposited  which  strongly  resemble  gall-stones.  Usually  the  irregularity  of 


Till-    IWTIIOl  OGICM.  CM  I  -lil  ADDKR  ig 

their  outline  is  sufficient  to  rule  out  gall-stones.  Careful  observation  will 
show  these  shadows  to  lie  in  the  region  oi  the  cartilage,  and  films  made  of  the 
corresponding  area  on  the  lelt  side  will  usuallj   show  a  similar  shadow.  II 

there  is  stili  doubt,  two  films  should  be  made  with  the  central  raj  comin 
from  a  different  direction.  Owing  to  the  fact  that   the  costal  cartilages  lie 

I  list  beneath  the  skin  and  pract  icalk  on  the  films,  the  relation  of  t  he  shadow 
to  the  end  ol  the  ribs  will  not  varj  with  the  change  in  the  position  of  the 
tube.  A  gall-stone  shadow,  however,  owing  to  its  location  at  some  distance 
from  the  plate,  will  varj  considerably  as  the  tube  varies  its  position. 

Renal  calculi  may  produce  shadows  hkek  to  be  confused  with  gall- 
stones. In  general,  kidnej  stones  are  denser  and  more  irregular  in  outline 
than  gall-stones.  A  kidney  stone,  ol  course,  will  always  be  situated  within 
the  kidnej  shadow,  no  matter  in  what  position  the  plate  is  mack'.  We  have 
found  that  the  lateral  vuiv  gives  us  reliable  differential  evidence.  In  a  true 
lateral  view  ol  the  abdomen,  kidney  stones  will  be  seen  lying  on  the  level  of 
or  posterior  to  the  anterior  edge  ol  the  bodies  of  the  vertebrae  (Plate  XI  l\  , 
Fig.  131).  Gall-stones,  on  the  other  hand,  if  situated  in  the  gall-bladder  will 
always  be  anterior  to  the  spine  and  lairk  close  to  the  anterior  abdominal 
walk  Gall-stones  in  the  duets  will,  of  course,  be  nearer  the  back,  but  even 
these  should  be  anterior  to  the  bodies  ol  the  vertebras. 

II  there  still  is  doubt,  an  injection  ol  the  kidnej  peh  is  and  ureter  w  ith 
some  opaque  solution  will  usually  decide  w  h  ether  a  certain  shadow  is  within 
the  kidney  or  not. 

Occasionally  a  calcified  tubercular  lymphatic  gland,  and  raick  some 
calcification  in  the  adrenal  gland,  may  give  a  confusing  shadow.  1  he  irregu- 
larity ol  their  outline  will  tend  to  rule  out  the  possibility  ol  gall-stones. 
Furthermore,  we  can  usually  demonstrate  that  these  gland  shadows  are 
situated  too  far  posteriorly  lor  gall-stones.  Glands  in  the  mesenterj  can  be 
diagnosed  from  the  fact  that  the\   are  beck    movable. 


20  THE  PATHOLOGICAL  GALL-BLADDER 

Finally,  small  collections  oj  gas  in  the  hepatic  flexure  or  in  the  duodenum 
may  produce  shadows  simulating  the  so-called  "negative  stones."  If  a 
shadow  under  suspicion  is  caused  by  gas,  its  center  will  be  much  darker 
than  the  shadow  of  the  surrounding  soft  tissue;  whereas,  if  it  is  produced  by 
a  stone,  the  center  of  the  shadow  will  be  about  the  same  density  as  the 
surrounding  soft  tissue.  Shadows  produced  by  gas  are,  of  course,  only 
temporary;  they  may  change  in  size  and  position  from  minute  to  minute, 
or  even  disappear  entirely.  This,  of  course,  is  the  most  important  differential 
point. 

Fecal  material  in  the  bowel  may  be  a  cause  for  error  in  the  interpreta- 
tion of  gall-stone  shadows.  A  careful  preliminary  preparation  of  the  patient 
will  usually  obviate  this  confusion,  or  the  examination  of  the  patient  on 
another  day  will  show  the  shadows  of  fecal  material  to  be  inconstant.  A 
study  of  the  barium-filled  hepatic  flexure  will  usually  remove  any  remaining 
uncertainty. 

Unusual  calcified  areas  in  diseased  kidney  or  liver  may  cast  shadows 
simulating  stones.  Such  conditions  are  so  rare  that  for  practical  purposes 
they  need  not  be  considered  in  a.  differential  diagnosis. 

In  the  same  category  may  be  considered  foreign  bodies  in  the  gastro- 
intestinal tract.  Theoretically,  certain  types  of  foreign  bodies  (such  as 
buttons)  may  cast  a  shadow  resembling  gall-stones.  And  not  uncommonly 
certain  conditions  in  the  skin  of  the  patient  may  produce  unusual  shadows 
on  the  film.  Small  papillomata  when  actually  in  contact  with  the  cassette 
may  produce  a  shadow  suggesting  a  gall-stone  shadow.  Simple  moles  may 
also  produce  the  same  appearance. 

The  Visible  Pathological  Gall-Bladder 

Under  the  general  heading  of  direct  evidence  we  not  only  have  the 
demonstration  of  actual  gall-stones,  but  also  the  visualization  of  the  gall- 


THE  I'M  HOI  OCICAI    CAN  -P.I  ADDI  I:  21 

bladder  itself.  I  his  demonstration  oi  the  outline  "I  the  actual  gall-bladder 
first  at t racted  our  attention  in  cases  where  gall-stones  were  clearlj  outlined. 
Careful  observation  oi  these  cases  frequently  revealed  a  fainl  globular 
shadow  surrounding  the  stone  shadows,  ihen  later,  as  we  studied  the  so- 
called  "suspicious"  shadows,  we  frequently  found  that  these  indefinite,  but 
abnormal,  densities  in  the  right  upper  quadrant  resolved  themselves  into 
shadows  ha\  ing  the  size,  shape,  and  posit  ion  ol  gall-bladders.  Finally  ,  in  op<  1 
ated  cases  where  targe  hydrops  conditions  had  been  found,  we  ascertained 
on  reexamining  the  plates  that  the  outline  ol  the  enlarged  bladder  was  clearlj 
seen,  its  shadow,  because  ol  its  size,  having  been  mistaken  for  the  kidney. 

Therefore,  it  gradually  dawned  upon  us  that  under  certain  conditions 
the  gall-bladder  itsell  was  visible.  We  then  began]  to  look  for  the  gall- 
bladder shadow  in  all  eases.  We  soon  observed  that  in  east's  coming  to  opera- 
tion   where   the  gall-bladder   had    been    outlined    on    the   him,   some    sort    ol 

pathology  was  invariably  found  in  the  gall-bladder.  Our  operative  results 
finally  forced  upon  us  the  conclusion  that  with  the  present  technique  a 
gall-bladder  might  produce  a  shadow  on  the  X-ray  plate  or  film  if  some  cha  nj  < 
from  the  normal  had  altered  its  density,  for  instance,  if  it  was  considerably 
distended,  its  walls  thickened,  or  its  contents  consisted  of  stones  or  abnormal 
bile,  there  was  a  \cr\  good  chance  that  its  outline  would  be  seen  on  the  \-ra\ 
plate.  The  converse  ol  this  proposition  we  have  come  to  use  as  a  workin 
hypothesis.  Perhaps  it  has  no  scientific  proof,  but  the  practical  working  out 
of  tin-  rule  has  demonstrated,  to  our  satisfaction,  its  reliability:  namely, 
il  the  shadow  ol  the  gall-bladder  is  seen  in  the  v-ra\  lilm,  it  indicates  that 
the  gall-bladder  is  pathological. 

Our  operative  results,  covering  the  last  few  years,  have  shown  us  that 
this  hypothesis  is  a  safe  guide.  While  it  does  not  represent  a  scientifically 
proved  statement  ol  fact,  yet  for  practical  purposes  we  consider  it  a  safe 
rule.  Doubtless  the  time  will  come  when,  with  improved  technique,  one  will 


6 


22  THE  PATHOLOGICAL  GALL-BLADDER 

be  enabled  to  visualize  the  normal  gall-bladder.  With  the  present-day 
methods,  however,  such  a  demonstration  seems  unlikely. 

Some  investigators  have  felt  that  the  normal  gall-bladder  shadow  is 
occasionally  visualized.  They  have  based  this  observation  in  some  cases  on 
the  fact  that  the  gall-bladder  shadow  was  seen  on  the  plate,  yet  at  operation 
the  surgeon  reported  the  gall-bladder  to  be  normal.  We  are  convinced,  and 
in  this  many  of  our  local  surgical  friends  concur,  that  one  cannot  tell  by  looking 
at  a  gall-bladder  or  feeling  it  whether  or  not  it  is  normal.  Therefore,  one 
should  hesitate  before  asserting  that  a  certain  shadow  represents  a  normal 
gall-bladder,  unless  the  surgeon  has  removed  the  gall-bladder  and  had  it 
examined  by  a  competent  pathologist. 

Incidentally,  in  addition  to  the  ordinary  pathological  evidence  of  a 
diseased  gall-bladder,  we  have  always  considered  that  any  change  in  the 
color  or  consistency  of  the  bile  is  also  evidence  of  gall-bladder  disease.  In 
this  opinion  we  are  definitely  supported. 

Again,  we  have  had  films  and  plates  shown  us  as  representing  normal 
gall-bladders,  in  which  the  shadows  interpreted  as  those  of  gall-bladders 
were  clearly  not  of  gall-bladders,  but  either  of  kidneys  or  of  one  of  the 
various  conditions  discussed  under  differential  diagnosis.  One  must  be 
extremely  careful  before  asserting  that  a  certain  shadow  in  the  right 
upper  quadrant  actually  represents  the  gall-bladder. 

Finally,  we  frequently  see  films  from  which  a  diagnosis  of  pathological 
gall-bladder  has  been  made  which  were  technically  so  poor  that  the  lower 
edge  of  the  fiver  could  not  be  identified.  Opinions  that  a  gall-bladder  is 
normal,  based  on  technically  poor  plates,  should  not  be  seriously  considered. 

Position  of  the  Gall-Bladder  Shadow 

The  gall-bladder  shadow  is  usually  observed  in  the  right  upper  quad- 
rant, in  close  proximity  to  and  just  below  the  lower  edge  of  the  liver.  Oc- 


Till-.   PAT1IOI  OCICAI     CAM  -I'.l    \l>l>l  R  23 

casionally  a  gall-bladder  shadow  may  be  in  such  relation  to  the  lower  surface 
of  the  liver  thai  its  shadow  appears  to  show  through  tin'  liver  substance. 
In  stout  individuals  it  frequently  lies  in  the  outer  hall  oi  the  right  upper 
quadrant;  in  thinner  patientSj  it  lies  nearer  the  median  line,  occasionally 
partlj  overlying  t  he  spine. 

The  level  of  the  gall-bladder  will,  of  course,  vary  with  the  position  ol 

the    lower  edge  of  the   liver.    Here  again,    in    well-nourished    individuals,    its 

shadow  will  be  seen  high  upon  the  right  sick';  in  thin  people  or  patients  with 
general  ptosis,  it  may  be  seen  well  down  in  the  right  Hank,  and  occasionally 
below  the  crest  ol  the  ilium. 

Shape   \\i>  Size  of    mii    G all-Bladder  Shadow 

The  ordinary  gall-bladder  as  seen  in  the  x-ray  plate  or  film  is  oval  in 
shape,  the  long  diameter  being  vertical  or  inclining  toward  the  median 
hue  in  thin  individuals.  Frequently,  in  the  well-nourished,  its  long  diameter 
ma\  be  nearb  horizontal.  I  he  lower  pole  or  lower  edge  ol  the  gall-bladder 
is  usually  the  more  clearly  seen,  the  upper  pole  being  obscured  by  the 
density  ol  the  liver  t issue. 

The  gall-bladder  shadow  presents  a  marked  variation  in  size  in  different 
individuals.  We  have  observed  chronic  gall-bladders,  which  are  contracted 
about  a  single  stone,  practically  containing  no  bile  and  w  it  h  thickened  w  alls, 
the  whole  mass  being  no  larger  than  an  English  walnut.  On  the  other  hand, 
with  complete  obstruction  of  the  cystic  duet,  the  lower  pole  ol  the  bladder 

may  reach  the  brim  ol  the  pelvis,  the  whole  sausage-shaped  mass  measuring 

over  8  inches  in  length  (Plate  XXII,  Fig.  71). 

Dim  i  hi  ntiai    Di  ^.GNOSIS 

There  are  several  conditions  likely  to  be  mistaken  lor  the  gall-bladder 
shadow.  Perhaps  the  most  confusing  is  the  kidnej  shadow.  It  is  a  good  rule 


24  THE  PATHOLOGICAL  GALL-BLADDER 

to  hesitate  before  interpreting  a  shadow  in  the  right  upper  quadrant  as  a 
gall-bladder  unless  the  outline  of  the  kidney  is  also  clearly  visualized.  There 
is  opportunity  for  error  in  reporting  a  gall-bladder  without  a  visible  kidney, 
for  the  chances  are  that  the  shadow  seen  is  the  kidney  rather  than  the  gall- 
bladder. 

One  helpful  point  is  the  distinctness  with  which  the  inner  edge  of  the 
gall-bladder  is  usually  seen  in  contradistinction  to  the  inner  edge  of  the 
kidney.  The  anatomical  structure  of  the  kidney  is  such,  with  the  pelvis  on 
the  inner  side,  that  this  margin  is  not  clearly  seen.  At  times  the  kidney  may 
be  displaced  or  rotated  so  that  the  pelvis  is  more  or  less  posterior.  Its  shadow 
under  these  circumstances  is  very  confusing,  as  the  inner  edge  of  the  kidney 
then  resembles  the  edge  of  a  somewhat  enlarged  gall-bladder. 

If  the  kidney  outline  is  not  clearly  seen  in  the  front  view,  the  patient 
may  be  turned  on  his  back  and  a  routine  "kidney  plate"  made.  This  will 
frequently  give  the  size  and  position  of  the  kidney  and  enable  one  to  differ- 
entiate it  from  the  gall-bladder. 

An  unusual  contour  of  the  liver  edge  may  occasionally  be  confused  with 
a  gall-bladder  shadow.  This,  however,  is  not  likely  to  be  a  common  abnor- 
mality and  in  practice  rarely  has  to  be  considered  in  the  differential  diagnosis. 
The  so-called  Riedefs  lobe  may  simulate  very  closely  a  gall-bladder  shadow. 
The  differential  point  is:  If  we  are  dealing  with  a  Riedel's  lobe,  its 
outline  is  continuous  with,  and  of  the  same  density  as,  the  liver  edge.  The 
shadow  produced  by  the  gall-bladder,  however,  usually  appears  distinct 
from  the  liver  edge  and  of  different  density  from  the  liver  tissue. 

It  is  interesting  to  note  that  some  authors  consider  the  presence  of  a 
Riedel's  lobe  as  evidence  of  pathology  in  the  biliary  system. 

Stomach  and  intestinal  contents  may  occasionally  be  of  such  a  nature 
as  to  cast  a  shadow  on  the  film.  If  these  shadows  happen  to  be  in  the  right 
upper  quadrant,  they  may  be  confused  with  a  possible  gall-bladder  shadow. 


I  111    I'M  IIOI  OGICAL  GAI  1  -Bl  \l)l)l  U  25 

This  is  particularly  true  oi  a  "food-filled"  duodenum,  the  duodenal  cap 
frequenl  K  having  more  or  less  the  shape  ol  a  gall-bladder,  and  with  a  similar 
smooth  margin.  Food  is,  ol  course,  continually  passing  through  the  duo- 
denum, so  that  a  food  shadow  will  be  inconstant.  11ns  is  the  importanl 
differentia]  point.  II  at  the  end  of  an  examination,  there  is  still  doubt  as  to 
whether  a  certain  shadow  is  the  gall-bladder  or  food  in  the  duodenum,  the 
patient  may  be  asked  to  return  on  another  day,  taking  the  precautionary 
measure  ol  an  emptj  stomach. 

Fecal  material  in  the  hepatic  flexure  ma\  also  be  confusing  when  one  is 
looking  lor  a  gall-bladder  shadow  .  I  his  ma \  be  ruled  out  in  the  same  general 
w;i\  as  a  food-filled  duodenum.  In  addition,  a  study  ol  the  twenty-four-hour 
filled  film  will  definitely  identify  the  hepatic  flexure,  this  portion  ol  the 
colon  being  filled  with  barium  at  that  time.  II  the  shadow  suggesting  the 

gall-bladder  is  still  seen,  one  would  be  warranted  in  considering  it  positively 

a  gall-bladder  shadow . 

Certain  tumor  masses  in  rari'  eases  ma\  produce  shadows  in  the  right 
upper  quadrant  likelj  to  be  confused  with  pathological  gall-bladders.  ( lancer 
of  t In-  head  of  the  pancreas  or  ol  the  pyloric  end  ol  the  stomach  is  the  most 
common.  The  differential  diagnosis  depends  on  the  lack  ol  a  discrete  margin 
to  a  shadow  produced  by  a  growth  ol  the  pancreas  or  stomach,  the  margin 
ol  the  shadow  ol  an  enlarged  gall-bladder  being  usually  sharp  and  clean  cut. 

Furthermore,  in  cases  ol  malignant  tumors  ol  sufficient  size  to  cast  a  shadow 
on  the  plate,  there  will  be  enough  indirect  evidence  to  make  the  diagnosis 
clear.  The  character  ol  the  deformitj  ol  the  stomach  and  duodenum  due  to 
cancer  in  the  right  upper  quadrant   is  almost  pathognomonic. 

Iii  rare  cases  it  ma\  be  ol  help  in  a  differential  diagnosis  to  examine  a 
patient  alter  a  pneumoperitoneum.  We  have  not  used  this  method  to  any 
extent   in  our  ow  n  practice. 


26  THE  PATHOLOGICAL  GALL-BLADDER 

Indirect  Evidence 
The  direct  evidence  of  gall-bladder  disease  is  obtained  from  plates  and 
films  made  directly  of  the  gall-bladder  region.  The  evidence  consists,  in 
general,  as  we  have  seen,  of  a  demonstration  of  gall-stones  or  of  the  patho- 
logical gall-bladder.  The  indirect  evidence  of  gall-bladder  disease  is  obtained 
by  a  study  of  the  various  organs  surrounding  the  gall-bladder.  These  organs, 
of  course,  are  not  visible  without  a  barium  meal.  The  search  for  indirect 
evidence  is,  therefore,  always  made  after  a  barium  meal. 

Deformities  Due  to  Pressure 

The  most  common  type  of  indirect  evidence  is  the  deformity  of  the 
duodenum  or  stomach  due  to  pressure  from  the  gall-bladder  (Plate  XXVIII, 
Fig.  8-;  Plate  XXXII,  Fig.  98;  Plate  XXXIII,  Figs.  100  and  101).  This 
pressure  deformity  has  a  characteristic  appearance,  which  is  best  understood 
by  a  study  of  the  films  or  plates.  The  value  of  this  type  of  evidence  lies  in  the 
fact  that  in  our  experience  this  deformity  is  never  produced  by  a  normal  gall- 
bladder. This  may  be  explained  by  the  theory  that  the  tension  within  the 
normal  gall-bladder  is  less  than  the  tension  within  the  food-filled  duodenum 
or  stomach.  In  other  words,  the  normal  gall-bladder  is  more  easily  compressed 
than  the  stomach.  Hence  the  stomach  or  duodenum  when  brought  into  con- 
tact with  the  normal  gall-bladder  will  compress  the  gall-bladder,  rather  than 
be  deformed  itself  by  the  gall-bladder. 

When  pathological  changes  take  place  in  the  gall-bladder — thickening 
of  the  walls,  increased  fluid,  or  stones — then  the  pressure  within  the  gall- 
bladder may  become  greater  than  the  pressure  within  the  stomach.  Under 
these  circumstances,  the  stomach  or  duodenum  will  be  compressed  by  the 
gall-bladder  and  the  typical  "pressure  delect"  produced.  The  deformity  is 
usually  seen  in  the  first  or  second  portion  of  the  duodenum,  but  it  may 
involve  the  greater  curvature   of  the  stomach,    near   the   pylorus    (Plate 


THE  IWTIIOI  OGICAL  G  A I  1  -P.I   \I)I>1  R  27 

XXXII  I,  Figs.  1  on  and  101  1.  1  hedeformitj  is  in  the  nature  oi  an  indentation 
on  tlu'  viscus,  1  lu'  indentation  apparently  being  produced  l)\  some  smooth, 
rounded  object,  rhere  is  usuallj  no"irreguIantj  in  the  outline  ol  t lu-  duod<  - 
mini  or  stomach  111  the  area  involved,  the  margin  being  smooth  and  the 
indentation  in  the  form  ol  a  concave  curve.  I  he  arc  of  the  curve  is  more  or  less 
constant,  represent  ing  thai  port  ion  ol  the  gall-bladder  thai  is  in  contad  with 
t he  duodenum  or  stomach. 

When  involving  the  duodenum,  the  deformitj  is  usuallj  on  its  outer 
edge.  In  a  centrally  situated  gall-bladder,  the  inner  edge  ol  the  duodenum 
max  he  involved. 

Occasionally  the  superior  angle  may  be  flattened  In  the  gall-bladder. 
Such  a  situation  produces  a  more  or  less  rectangular  shape  ol  the  duodenum, 
and  m  marked  cases  produces  a  much  "flattened"  cap,  tin-  vertical  diameter 
being  greatlj  narrowed.  Tins  particular  deformity  ol  the  cap  is  seen  most 
frequently  in  the  lateral  position.  As  we  have  just  stated,  the  margin  oi  this 
deformity  is  usually  smooth.  In  rare  cases,  however,  it  will  have  a  somewhal 
"scalloped"  appearance  (Plate  XXXIII,  big.  102)  due  to  pressure  oi  sunn 
actual  stones  within  the  gall-bladder. 

The  second  portion  ol  the  duodenum  will  at  times  show  the  effect  ol 
gall-bladder  pressure  (Plate  XXXIX,  big.  Il6).  The  pressure  deformity 
shows  the  same  characteristic  type  ol  curve  as  seen  in  the  Inst  portion.  I  he 
deformity  ol  this  part  ol  the  duodenum  is  usuallj  associated  with  fixation  due 
to  adhesions,  which  will  be  discussed  later. 

When  involving  the  stomach,  the  pressure  dclormitx  is  in  the  antrum 
on  the  greater  curvature  (  Plate  WW  I,  b  igs.  [  09  and  110).  1 1  ere  again  the 
curve  has  the  same  characteristic  arc.  I  Ins  deformitj  is  seen  best  withthe 
patient  in  the  prone  position,  when,  particularly  In  stout  individuals,  the 
antrum  is  forced  into  t  he  right  upper  quadrant,  thus  coming  into  contact  with 
the  gall-bladder.  Usually  in  the  uprighl  posit  ion,  the  stomach  falls  awaj  from 


28  THE  PATHOLOGICAL  GALL-BLADDER 

the  right  upper  quadrant  and  the  pressure  defect  of  the  gall-bladder  becomes 
obliterated.  Occasionally,  however,  the  antrum  of  the  stomach  may  be  fixed 
by  adhesions  in  the  right  upper  quadrant,  so  that  even  in  the  upright  position 
the  gall-bladder  pressure  will  still  be  seen. 

In  the  interpretation  of  these  curved  pressure  defects,  one  should  bear 
in  mind  that  while  an  enlarged  gall-bladder  is  almost  always  the  cause  of  the 
deformity,  still  there  are  rare  exceptions  that  should  be  borne  in  mind.  An 
abnormal  contour  of  the  under  surface  of  the  liver  might  produce  a  similar 
deformity;  likewise,  an  enlarged  or  freely  movable  kidney.  Various  rare 
forms  of  new  growth,  particularly  of  the  cystic  type,  or  where  the  tumor  mass 
has  a  rounded  and  smooth  surface,  might  cause  pressure  similar  to  an  enlarged 
gall-bladder.  In  this  last  class  are  the  cystic  conditions  of  the  head  of  the 
pancreas. 

Secondarv  Changes  Due  to  Adhesions 

We  now  come  to  the  consideration  of  other  changes  in  adjacent  organs 
(aside  from  those  caused  by  pressure)  that  are  secondary  to  gall-bladder 
disease.  Practically  all  these  changes  may  be  classified  under  the  general 
heading  of  adhesions.  We  shall  be  considering,  therefore,  the  various  mani- 
festations of  the  results  of  gall-bladder  adhesions  on  other  organs. 

First  Portion  of  the  Duodenum.  The  organ  most  frequently  affected 
by  gall-bladder  adhesions  is  the  first  portion  of  the  duodenum.  The  character 
of  the  changes  produced  in  the  first  portion  by  adhesions  group  themselves 
into  more  or  less  definite  types  of  filling  defect.  Perhaps  the  most  common— 
and  one  must  be  familiar  with  the  surgical  picture  to  appreciate  this  type  of 
filling  defect — is  as  if  strings  were  pulled  backward  and  forward  over  the 
anterior  surface  and  pulled  down  upon  the  first  portion,  giving  a  more  or  less 
toothed  appearance  (Plate  XXXV,  Fig.  107).  One  simple  and  not  very  reliable 
differentiation  between  this  condition  and  ulcer  is  that  adhesions  play  their 


[Ill     PATHOLOGICAL  (.Ml  -Bl   \l)l)l  K  jo 

most  deforming  role  a i  the  time  when  the  stomach  is  lull  rather  than  when  it 
is  partially  empty.  In  general,  the  ulcer  picture  is  nol  so  characteristic  im- 
mediately after  the  injection  oi  a  meal  as  a  little  wink'  later  in  the  examina- 
tion, rhe  ulcer-filling  defect  becomes  more  definite  up  to  a  certain  poim  in 
the  emptying  oi  the  stomach,  while  the  deforming  defects  from  gall-bladdei 
adhesions  gradually  disappear  as  the  stomach  empties  and  relaxes. 

1  he  second  type  ol  deformity  from  adhesions  involving  the  firsl  portion 
oi  the  duodenum  is  the  complete  obliteration  oi  the  normal  outline  oi  the 
duodenum,  the  lumen  becoming  tubular  in  character,  as  though  gripped  In 
a  firm  band  oi  adhesions  a  cent i meter  or  more  in  width.  I  his  condition,  too, 
may  be  confused  with  the  chronic  indurated  obliterative  type  oi  ulcer  i  Plate 
XXXIV,  Fig.  105). 

The  third  type  oi  filling  defect  commonly  met  with  is  a  combination  ol 
the  ulcer  picture  and  ol  adhesions,  and  it  becomes  dillicult  to  determine  by 
an\  means  except  surgerj  whether  the  deforming  delect  lound  in  the  duo- 
denum is  due  primarily  to  ulcer  or  to  adhesions,  or  to  both. 

Second  Portion  <</  the  Duodenum.  I  he  second  portion  of  the  duodenum  is 
frequently  the  site  of  changes  due  to  gall-bladder  disease.  In  addition  to  the 
deformities  due  to  pressure  already  spoken  ol,  we  have  changes  in  the  posit  ion 
and  outline  due  to  adhesions.  The  frequency  with  which  this  second  portion 
is  disturbed  by  gall-bladder  disease  is  c<  >ntrary  to  one's  expect  at  ions,  lor  this 
portion  is  usuallj   considered  to  be  more  or  less  retroperitoneal. 

The  most  common  deformity  is  an  apparent  picking  up  ol  t  he  descending 
or  second  portion  ol  the  duodenum,  displacing  it  and  fixing  it  toward  the 
right  'Plate  XXXIX,  Figs.  n6  and  m_i.  This  lateral  displacement  fre- 
quently produces  an  appearance  on  the  film  or  plate  as  though  the  fundus  oi 
the  gall-bladder  were  outlined  l>\  the  duodenum.  This  deform ii\  is  the  result 
ol  pressure  plus  an  adhesion  fixation. 

Occasionalb  one  linds  a  simple  narrow  ing  at  one  point  ol  the  duodenum. 


3o  THE  PATHOLOGICAL  GALL-BLADDER 

This  type  of  deformity  is  usually  due  to  one  single  band  of  adhesions  lying 
across  the  duodenum  (Plate  XL,  Fig.  120). 

Jejunum.  Another  opportunity  to  observe  secondary  manifestations 
of  gall-bladder  disease  may  be  found  in  the  study  of  the  jejunum.  Occasion- 
ally one  finds,  in  the  right  upper  quadrant,  loops  of  jejunum  filled  with  gas, 
showing  on  the  films  previous  to  the  ingestion  of  the  barium  meal.  If  this 
phenomenon  is  confirmed  when  the  jejunum  is  filled  with  barium,  it  becomes 
an  important  diagnostic  point  (Plate  XXXIV,  Fig.  105  and  Plate  XLII, 
Fig.  125). 

Barring  the  rare  possibility  of  a  congenital  malposition  of  the  small 
intestine  or  a  chronic  tubercular  peritonitis,  one  must  conclude  that  these 
loops  of  jejunum  are  displaced  and  fixed  by  adhesions  from  the  pathological 
gall-bladder. 

Colon.  An  important  organ  to  examine  for  changes  due  to  gall-bladder 
disease  is  the  colon  in  the  region  of  the  hepatic  flexure.  The  most  character- 
istic changes  in  the  hepatic  flexure  are  a  catching  up  and  "pulling  out"  ot  a 
small  portion  of  the  wall  of  the  colon.  The  resulting  deformity  has  the  ap- 
pearance of  a  sacculation  in  which  there  is  usually  a  collection  of  gas,  the 
main  lumen  of  the  colon  being  filled  with  the  barium  meal  (Plate  XXIV,  Fig. 
77).  This  projection  or  sacculation  is,  of  course,  due  to  an  adhesion  from  the 
gall-bladder,  and  therefore  is  always  located  close  to  the  gall-bladder.  This 
particular  type  of  deformity  is  almost  pathognomonic  of  gall-bladder  disease. 

There  may  be  a  general  deformity  of  the  hepatic  flexure  due  to  more 
extensive  gall-bladder  adhesions.  From  the  fact  that  these  general  adhesions 
are  in  the  right  upper  quadrant,  we  are  usually  safe  in  considering  them  as 
coming  from  the  gall-bladder.  However,  one  must  bear  in  mind  that  there 
may  be  other  sources  for  these  adhesions — a  long  retrocecal  appendix,  omen- 
tal adhesions,  or  tubercular  peritonitis.  There  is,  however,  a  more  or  less 
characteristic  deformity  of  the  hepatic  flexure  and  proximal  portion  of  the 


THE  PATHOLOGICAL  (,\l  I  -HI   \I)DI  R  51 

transverse  colon,  frequently  seen  as  a  result  ol  gall-bladder  disease,  rhis 
deformity  consists  oi  a  "picking  up"  and  fixing  ol  the  transverse  colon  al  a 
point  a  few  inches  distal  I  nun  the  hepatic  flexure  I  Plate  \l  1 1.  Fig.  127).  This 
product's  a  more  or  less  sharp  angulation  ol  the  transverse  colon,  and  we 
have  conic  to  speak  ol  it  as  a  "pseudohepatic  flexure." 

Finally,  we  have  the  simple  displacement  ol  the  hepatic  flexure  from  an 
enlarged  gall-bladder.  I  Ins  displacement  is  usually  downward  and  toward 
the  median  line  (Plate  XXII,  Fig.  71). 

Kidney.  In  the  differential  diagnosis  it  is  rarelj  necessarj  to  consider 
a  displacement  due  to  an  enlarged  or  low  kidney.  Fortunately,  the  kidnej 
does  not  usually  displace  the  hepatic  flexure.  When  it  does,  however,  the 
colon  usually  goes  clow  nw  aid  and  to  the  outer  side. 

Fixation  or  One,  \\s 
Quite  commonly  one  will  observe  no  deformity  in  the  outline  of  the 
various  organs  which  could  be  ascribed  to  adhesions,  but  there  will  be  a 
fixation  oi  the  part.  1  he  organ  may  be  "fixed"  in  its  normal  position  or  dis- 
placed and  fixed,  the  fixed  portion  always  being  close  to  the  gall-bladder. 
for  instance,  the  pyloric  vnd  ol  the  stomach  ma\  be  huind  far  over  to  the 
right  side  and  li\ed.  A  similar  situation  may  involve  the  hepatic  flexure. 
This  fixation  may  be  demonstrated  by  palpation  under  the  fluoroscopic 
screen,  or  by  taking  films  with  the  patient  prone  and  standing.  In  the  latter 
method,  the  "  fixed  "  portion  will  ha\  e  a  constant  relation  to  the  gall-bladder 
in  both  positions. 

Sp  vstic  Ch  VNGES   l\    I  III    Stom  \<  11 

1  In    pathological  gall-bladder,   like  the  chronic  appendix,   max    produce 

reflexly  various  spastic  manifestations  in  the  stomach.  These  spastic  changes 

in  general  do  not   differ  from   reflex   spasms  due  to  other  causes.  There  is, 

how  ever,  one  type  of  spasm  thai  in  our  experience  is  so  commonlj  associated 


32  THE  PATHOLOGICAL  GALL-BLADDER 

with  gall-bladder  disease  that  we  have  come  to  consider  it  when  present  as 
fairly  reliable  evidence.  This  type  of  spasm  affects  the  antrum  of  the  stomach. 
Usually  the  distal  third  of  the  stomach  becomes  uniformly  contracted,  pro- 
ducing a  tubular  outline  an  inch  or  so  in  diameter,  the  proximal  two-thirds 
maintaining  its  normal  diameter  (Plate  XLIII,  Fig.  129). 

Changes  in  the  Gall-Ducts 

Finally,  the  changes  observed  in  the  gall-ducts  are  very  important 
indirect  evidences.  We  have  noticed  from  time  to  time  a  small  speck  of 
barium  retained  close  to  the  second  portion  of  the  duodenum  but 
not  within  its  lumen  (Plate  XLI,  Fig.  123).  The  small  shadow  could 
frequently  be  seen  twenty-four  hours  after  the  barium  meal.  At  first  we 
considered  this  to  be  a  small  congenital  diverticulum  attached  to  the  second 
portion  of  the  duodenum;  but  repeated  occurrences  of  this  condition,  with 
the  shadow  always  bearing  a  constant  relation  to  the  duodenum,  have 
led  us  to  conclude  that  we  are  dealing  with  barium  in  the  ampulla  of  Vater. 
We  believe  that  under  certain  conditions  the  ampulla  becomes  dilated  or 
relaxed  so  as  to  allow  the  entrance  of  barium  into  it.  This  dilatation  might 
be  the  after-effect  of  the  passage  of  a  large  gall-stone  or  some  chronic  in- 
flammatory condition.  Possibly  some  interference  with  the  normal  How  o! 
bile  or  pancreatic  secretion  may  allow  this  phenomenon  to  take  place. 

We  consider  the  barium-filled  ampulla  to  be  practically  pathognomonic 
of  some  form  of  gall-bladder  or  pancreas  disease.  This  consideration  is 
based  on  the  fact  that  in  every  case  coming  to  operation  where  this  phenome- 
non was  observed,  a  pathological  condition  was  found  either  in  the  gall- 
bladder, in  the  ducts,  or  in  the  pancreas.  Again,  we  have  never  been  able  to 
demonstrate  a  barium-filled  ampulla  of  Vater  in  a  normal  individual,  either 
after  an  exhaustive  film  examination  or  with  palpation  under  the  fluoro- 
scopic screen. 


Chapter   I  \ 
CONCLUSION 

IN  conclusion,  let  us  remind  the  reader  that  the  value  ol  the  v-ray  in  the 
diagnosis  oi  gall-bladder  disease  depends,  first,  on  careful  attention  to 
the  details  ol  technique.  1  he  methods  for  preparing  the  patient  and  foi 
making  the  exposures  are  not  complicated  <>r  involved.  On  the  contrary, 
they  arc  extremely  simple,  but  Frequently  lack  ol  attention  in  some  appar- 
ently unimportant  detail  is  what  stands  between  success  and  failure. 

Secondly,  the  diagnosis  ol  gall-bladder  disease  is  not  limited  to  the 
demonstration  ol  gall-stones.  I  he  diagnosis  is  made  on  a  great  mass  ol 
direct  and  indirect  evidence.  I  he  degree  ol  positiveness  ol  the  diagnosis 
depends  on  the  amount  ol  evidence.  II  gall-stones  are  visible,  the  diagno- 
sis is  positive.  On  the  other  hand,  il  the  entire  examination  reveals  only  one 
minor  type  ol  indirect  evidence,  such  as  a  suggestive  pressure  defect  on  the 
duodenum,  then  oiiI\  a  presumptive  diagnosis  can  he  made';  or,  as  we  fre- 
quently report,  "the  evidence  is  consistent  with  gall-bladder  disease." 

Finally,  we  have  endeavored  not  to  elaborate  some  scientifically  proved 
method  ol  diagnosis,  but  rather  to  report  our  progress  toward  the  ultimate 
solution  ol  one  ol  the  most  dilhcult  problems  before  the  medical  profession. 
II  this  modest  work  should  by  chance  stimulate  some  one  to  "carry  on" 
in  this  pioneer  held  ol  roentgenology,  we  shall  rest  content. 

Statisi  k  s 

The  writers  realize  the  inaccuracy  ol  statistics  as  well  as  anyone.  The 
following  figures  are  offered,  however,  as  something  ol  a  guide.  I  hey  repre- 
sent a  summary  ol  a  scries  ol  cases  which  were  referred  to  us  and  on  w  Inch  we 
reported  m  turn  to  the  consultant,  from  January  i,  [920  to  November  1, 
1920,  making  a  total  ol  ten  months.  During  this  time  we  Imd,  on  going  oxer 
our  records,  that  we  passed  an  opinion  in  746  cases  either  on  the  positive 
or  negative  aspect   ol    the  gall-bladder  examination.    In   some   instances  we 


ii 


34  THE  PATHOLOGICAL  GALL-BLADDER 

knew  the  cases  were  referred  for  distinctly  definite  lesions  of  the  stomach, 
the  physician  expecting  from  the  clinical  evidence  to  find  ulcer  or  cancer. 
Nevertheless,  in  these  cases,  in  an  effort  to  base  our  knowledge  of  gall-bladder 
disease  upon  the  surgical  findings  from  as  great  a  number  of  cases  as  possible, 
we  reported  to  the  consultant  any  suggestive  shadows  that  seemed  abnormal 
in  the  gall-bladder.  We  hoped  that  the  surgeon  would  at  least  casually 
investigate  the  gall-bladder  and  help  us  to  determine  more  quickly  the  value 
of  certain  signs  which  seemed  definite  from  a  purely  roentgenographic 
point   of  view. 

In  order  not  to  include  any  personal  equation  in  compiling  these  statis- 
tics, we  gave  all  our  reports  and  the  letters  received  from  the  medical  men 
and  surgical  consultants  who  replied  to  our  request  for  the  surgical  findings, 
to  a  disinterested  individual.  She  compiled  them  simply  from  a  statistical 
point  of  view,  using  her  judgment  in  interpreting  the  reports  as  to  whether 
they  were  positive  or  negative.  Out  of  a  total  of  746  cases  reported  on  during 
this  period  of  time,  128  were  operated  upon  and  reported  to  us  as  to  the  sur- 
gical findings.  These  eases  are  included  in  the  statistics.  Some  medical  men 
did  not  answer  our  letters.  Undoubtedly,  some  eases  have  been  operated 
upon,  or  will  be,  of  which  we  have  no  knowledge. 

Of  the  128  operative  cases,  eight  diagnoses  were  proved  wrong  on  the 
negative  aspect  and  seven  on  the  positive,  making  the  percentage  of  correct 
diagnoses  88.4  with  a  percentage  of  error  of  1 1.6  per  cent. 

Reported  between  January  1,  1920  and  November  1,  1920. 

(Total  of  positive  and  negative  opinions).  "46  cases 

Operative  findings  reported  on 128  cases 

Correct  interpretation  in  X-ray  examination 114  cases 

Errors 15  cases 

Percentage  (correct) 88 . 4  per  cent. 

Percentage  (incorrect) 1 1 . 6  per  cent. 


ROENTGEN  PLATES  OF 

PATHOLOGICAL  GALL-BLADDERS 

THAT  MAY  OR  MAY  NOT 

CONTAIN  GALL-STONES 


PATHOLOGICAL   GALL-BLADDERS   CONTAINING 

GAI  L-STON1  S 

l\  the  studj  ol  the  individual  case  for  the  detection  oi  gall-stones,  the 
difficulty  in  demonstrating  or  making  visible  the  gall-stones  is  partlj  a 
physical  problem,  but  mostlj  lack  oi  care  in  the  essential  details  ol  the  x-ray 
examination,  loo  much  emphasis  cannot  be  laid  upon  the  necessity  oi 
immobilizing,  not  only  the  part  to  be  taken,  but  the  respiratorj  motions. 
The  slightest  amount  oj  breathing  in  itsell  will  make  invisible  even  a  fairlj 
definite  calcium  stone  (Plate  X,  Figs.  30  and  51).  We  feel  that  stones  ol 
reasonable  size  and  density  are  usually  visible  eventually,  with  perseverance 
as  to  the  number  oi  films  and  extreme  care  in  the  amount  of  milliamperage 
and  voltage  used,  and,  most  ol  all,  with  attention  to  the  immobilization  oj  tin 
part. 

Secondary  in  importance  is  the  examination  ol  the  whole  region  in  which 
the  gall-stones  max  be  found.  One  must  not  overlook  any  part  of  the  right 
upper  quadrant,  sometimes  going  down  to  and  below  the  crest  of  the  ilium. 
One  never  knows  where  the  stone  may  be  found. 

Errors  may  arise  and  have  occurred  in  the  writers'  experience,  through 
superficial  skin  defects,  such  as  moles,  warts,  etc.,  through  scars  on  the 
anterior  abdominal  wall  and  on  the  back,  through  calcified  mesenteric  glands, 
foreign  bodies  in  the  colon,  calcification  oi  the  liver,  calcification  of  the 
pancreas,  irregular  calcification  of  the  costal  cartilage,  stones  and  calcified 
areas  within  the  right  kidney,  and  rarely  through  myositis  ossificans  of  the 
deep    muscles.    In    the   type  of  stone   that    In     its   chemical    make-up    is    not 

dense  enough  or  oi  atomic  weight  sufficient  to  cast  a  shadow  either  of  the 

periphery  or  ol  the  nucleus,  w  c  are  able  at  tunes  to  make  visible  the  mass  b\ 

its  increased  density.  Occasionally,  even  in  difficult  types  of  stones,  it   is 

57 


PLATE  I 

Visible  gall-stones.     This  examination  was  made  with  the  Potter-Bucky  diaphragm. 

PLANCHE  I 

Calculs  biliaires  radiographics  avec  I'antidifTuseur  Potter-Bucky. 

PLANCHA  I 

Calculos  visibles.  EI  exanien  se  hizo  con  el  antidiiusor  Potter-Bucky. 


GEORGE  6?  LEONARD     GALL-BLADDER 


PLATI    I 


ANNALS  Ol 
reiENOLOGY,  VOL.   I! 


i  [SHI  D    BY 


PATHOLOGICAL   ( ,  Al  I  -Bl.ADDLUs  39 

possible  to  make  one  individual  stone  stand  out  even  in  a  collection  oi  a  larger 
number  oi  in\  isible  stones. 

1  he  position  oi  the  patienl  on  the  plate  and  in  relation  to  the  tube 
(Figs.  1  and  2)  is  oi  the  utmost  importance,  and  an  efforl  should  be  mack' 
to  obtain  a  series  oi  films  oi  the  right  quality  in  the  same  position,  rathei 
than  to  change  the  position  oi  the  patient  in  relation  to  the  tube.  The 
fatter  will  [ead  to  uncertainty  and  error. 


LES  VESICULES  BILIAIRES  M AI.ADI  S  II   CALCU- 

LEUSES 

Dans  la  recherche  des  calculs  biliaires  on  se  heurte,  sans  doute,  a  des 
difficultes  d'ordre  physique,  mais  la  plupart  des  obstacles  peuvent  etre 
surmontes  avec  une  technique  soignee.  On  ne  saurait  trop  insister  sur  la 
necessite  d'immobiliser  non  seulemenl  la  region,  mais  aussi  les  visceres, 
en  suspendant  la  respiration.  Le  plus  jaible  mouvement  respiratoire  peut 
effacer  un  calcul  qui,  sans  cela,  serait  bien  visible  (planche  X,  figs.  50  e1 
31).  Nous  nous  croyons  en  droit  d'affirmer  que  tout  calcul  de  taille  ou  de 
consistance  raisonnables  pent  se  montrer  si  Ton  ne  se  rebute  pas,  si  Ton  ne 
neglige  pas  les  details  de  la  prist'  du  cliche,  et,  surtout,  m  Von  immobilise 
le  sujet. 

On  ne  negligera  pas,  non  plus,  d'explorer  toute  la  zone  ou  peut  se 
trouver  une  vesicule.  Non  seulement  il  faut  balayer  tout  I'hypochondre 
droit,  mais,  parlors,  descendre,  [usqu'a  la  crete  iliaque  et  meme  plus  bus. 
On  ne  sait  jamais  OU  pent  se  blottir  un  ealeul. 

Une  cause  d'erreur  possible,  a  not  re  connaissance,  e'est  la  presence  de 
verrues,  loupes  ou  autres  excroissances  cutanees.  Des  cicatrices  de  la  paroi 
abdominale  ou   dorsale,  des  ganglions   mesenteriques  cretaces,  des  corps 


4o  PATHOLOGICAL  GALL-BLADDERS 

etrangers  du  colon,  des  calcifications  du  foie  ou  du  pancreas,  des  depots 
calcaires  dans  Ies  cartilages  costaux,  des  calculs  ou  des  depots  calcaires 
dans  Ie  rein  droit,  exceptionellement  la  myosite  ossifiante,  tout  cela  pent 
simuler  Ie  calcul  biliaire.  Quand  Ies  calculs  pris  individuellement  n'ont  pas 
une  composition  chimique  permettant  d'en  obtenir  une  ombre,  Ieur  groupe- 
ment  pent  constituer  une  masse  assez  dense  pour  Ieur  permettre  de  se 
reveler  sur  Ie  cliche.  Parfois,  meme  dans  un  amas  de  calculs  pen  visibles, 
un  d'entre  eux  se  montrera  clairement. 

La  position  du  malade  et  de  I' ampoule  (figs,  i  et  2), est  tres  importante. 
Mieux  vaut  obtenir  une  serie  de  plaques  de  bonne  qualite  photographique 
sans  rien  deplacer,  que  de  modifier  sans  cesse  I' orientation  du  tube;  cette 
derniere  pratique  engendre  des  hesitations  et  des  erreurs. 

INVESTIGACION  DE  LOS  CALCULOS  BILIARES 

No  hay  duda  de  que  la  investigacion  de  Ios  calculos  biliares,  si  no  es 
metodica,  tropieza  con  serias  dificultades  de  orden  fisico,  que,  sin  embargo, 
el  empleo  de  una  tecnica  cuidadosamente  reglada  podra  veneer  el  mayor 
numero  de  veces.  En  ninguna  otra  ocasion  son  tan  necesarias  e  imperiosas, 
como  en  esta,  la  inmovilidad  de  la  region  examinada  y  la  suspension  absoluta 
de  la  respiracion.  EI  mas  breve  movimiento  respiratorio  puede,  por  si  solo,  velar 
y  haeer,  desde  Iuego,  invisibles  hasta  las  imagenes  de  calculos  moderada- 
mente  ricos  en  calcium  que,  sin  esta  circunstancia,  habrian  aparecido  nitidos 
en  Ios  roentgenogramas  (Plancha  X,  Figs.  30  y  31).  Nosotros  creemos  no 
incurrir  en  error  al  sostener  que  ordinariamente  es  posible  obtener  la  imagen 
de  cualginer  calculo  de  tamaho  y  consistencia  medianos,  con  tal  que  se 
impresionen  varias  peliculas,  se  consuma  elcorrecto  numero  de  miliamperios 
a  un  voltaje  adecuado  y  rio  se  descuide,  ante  todo,  la  inmovilizacion  del 
sujeto. 


PATIIOI.OGICAI     GAI  L-M   \DDL;RS  41 

Es  asimismo  importante  extender  la  exploracion  a  toda  la  zona  en  la 
cual  puedan  encontrarse  calculos  biliares.  No  solo  debe  de  examinarse  todoel 
hipocondrio  derecho  sino  que,  a  veces,  es  necesario  descender  nasta,  \  aun 
por  debajo,  de  la  cresta  iliaca,  puesto  que  nunca  se  sabe  donde  fijamente  esta 
el  calculo. 

Nuestra  experiencia  nos  ha  advertido  de  varias  causas  tic  error  posible, 
tales  sou:  la  presencia  de  verrugaSj  unares,  angiomas  \  otras  excrecencias 
cutaneas;  las  cicatrices  en  la  pared  abdominal  y  en  la  espalda;  los ganglios 
mesenteric! >s  cretaceos;  Ins  cuerpos  ex1  ranos  del  colon;  Ins  depositos  calcareos 
en  el  higado  \  el  pancreas;  la  calcificacion  irregular  de  Ids  cartilagos  costales; 
los  calculos  \  los  depositos  calcareos  en  el  rinon  derecho  \ ,  excepcionalmente, 
la  miositis  osificante  de  los  musculos  profundos. 

Cuando  la  composicion  quimica  de  los  diversos  calculos  de  un  grupo, 
considerados  aisladamente,  es  tal  que  ni  su  peso  atomico  ni  su  densidad  Ie 
permiten  proyectar  una  sombra,  bien  sea  de  la  periferia,  bien  del  nucleo,  del 
calculo,  ocurre  sin  embargo,  que  su  agrupamiento  puede  constituir  una 
masa  bastante  densa  para  revelarse  claramente  en  el  disc.  A  veces  tambien 
sucede  que  en  un  paquete  de  calculos  poco  visibles  mm,  entre  todos,  da  una 
imagen  netamente  visible. 

La  posicion  del  enfermo  con  relacion  a  la  placa  fotografica  \  a  la  ampolla 
radiogena  (Figs.  1  >  2)  dc  gran  importancia.  Valem  as  obtener  una  serie 
de  peliculas  de  buena  cualidad  en  la  misma  posicion  de  sujeto  y  ampolla,  que 
alterando  las  relaciones  de  uno 3  otra;  esto  ultimo  conduce  a  la  incertidumbre 
v  al  error. 


PLAIT.  II 


PLANCIII     II 


PLANCHA  II 


PLATE   II 

Fig.  3.  Woman,  aged  thirty-five.  A  mass  of  stones  in  the  gall-bladder  and  one  in  the 
cystic  duct.  Illustrates  the  type  of  dense  gall-stones  containing  more  calcium  than  the  usual 
gall-stone,  and,  in  the  experience  of  the  writers,  the  only  instance  in  which  the  stones  cast 
such  a  definite  shadow  as  is  found  in  this  case.  Also  illustrates  the  location  of  the  gall-bladder 
in  thin  and  poorly  nourished  men  or  women,  especially  in  women.  By  the  relation  of 
the  gall-bladder,  though  the  stomach  is  not  illustrated,  one  can  seehow  the  pressure  of 
these  stones,  even  though  they  should  prove  to  be  a  negative  shadow,  would  cause  de- 
formity of  either  the  stomach  or  duodenum,  either  by  fixation  of  a  portion  of  the  stomach 
or  of  the  gall-bladder,  or  by  pressure  against  the  stomach  or  the  second  portion  of  the 
duodenum.  If  all  gall-stones  were  of  the  density  of  these  stones,  they  would  be  as  easily 
recognized  by  the  x-ray  as  kidney  stones.  This  is  the  unusual  type  of  very  dense  gall- 
stones, rarely  seen. 

Fig.  4.     A  large  number  of  gall-stones. 

Fig.  5.     The  gall-bladder  full  of  almost  pure  bilirubin  lime  stones. 

PLANCHE  II 

Fig.  3.  Femme  de  35  ans-  Un  amas  de  calculs  dans  la  vesicule,  un  autre  dans  le  canal 
cystique.  Nous  avons  ici  des  calculs  exceptionnellement  riches  en  calcium,  portant  les  ombres 
les  plus  nettes  que  les  auteurs  aient  rencontrees.  Le  cliche  montre  aussi  la  situation  ordinaire 
de  la  vesicule  chez  des  sujets  maigres  ou  denourris,  generalement  du  sexe  feminin.  Par  la 
seule  position  de  la  vesicule,  bien  que  I'estomac  ne  soit  pas  visible,  on  se  rend  compte  des 
tiraillements  et  des  compressions  que  la  vesicule  biliaire  peut  exercer  sur  I'estomac  ou  sur 
la  seconde  partie  du  duodenum.  Si  tous  les  calculs  biliaires  avaient  la  densite  de  ceux  figures 
ici,  on  les  decelerait  aussi  facilement  que  des  calculs  renaux.  On  en  rencontre  rarement 
d'aussi  opaques. 

Fig.  4.     Nombreux  calculs  biliaires. 

Fig.  5.     La  vesicule  remplie  de  calculs  a  base  de  bilirubinate  de  chaux  presque  pur. 

PLANCHA  II 

Fig.  3.  Mujer  de  35  anos;  Grupo  de  calculos  en  la  vesicula  y  uno  en  el  conducto 
cistico.  Pertenece  a  una  variedad  excesivamente  rica  en  calcio,  y  es  el  unico  ejemplar  en  que 
los  autores  han  podido  obtener  imagenes  tan  densas  y  precisas.  EI  clise  muestra  la  situacion 
de  la  vesicula  en  sujetos  flacos  y  mal  nutridos,  principalmente  mujeres.  Si  bien  no  ensena 
la  imagen  del  estomago,  en  cambio  la  posicion  anormal  de  la  vesicula  da  buena  idea  de 
como  la  presion  ejercida  por  dichos  calculos,  aunque  hubieran  sido  de  los  que  originan 
sombras  negativas,  es  causa  importante  y  frecuente  de  deformaciones  en  las  imagenes  del 
estomago  y  del  duodeno,  ora  fijando  un  segmento  del  estomago  a  la  misma  vesicula  biliar 
o  bien  comprimiendo  contra  el  estomago  la  segunda  porcion  del  duodeno.  Si  todos  los  cal- 
culos biliares  tuvieran  la  densidad  de  estos,  su  reconocimiento  seria  tan  facil  como  el  de  los 
renales;  pero  raras  veces  suelen  ser  tan  opacos. 

Fig.  4.     Numerosos  calculos  biliares. 

Fig.  5.     Vesicula  biliar  repleta  de  calculos  de  bihrubmato  de  cal  casi  puro. 


PLATE  [] 


k 


m 


Fig.  3- 


Fig.  4. 


Fig.  5. 


PLATE  II 


PLANCHE  III 


PLANCIIA  111 


PLATE  III 

Fig.  6.  Unusual  arrangement  of  calcium  shadows  which  suggest  one  single  stone, 
possibly  several  stones.  At  operation,  this  proved  to  be  one  single  stone. 

Fig.  7.  Same  case  as  shown  in  Fig.  6.  Barium-filled  stomach  showing  the  relation  of 
the  shadows  to  the  stomach. 

Fig.  8.  X-ray  of  the  gall-bladder  region  of  a  woman,  showing  several  faint  peripheral 
shadows  due  to  gall-stones. 

Fig.  9.  Two  gall-stones  in  a  woman,  aged  sixty.  Illustrates  one  type  of  the  character- 
istic peripheral  calcium  stone.  The  nucleus  has  very  little  density,  if  any.  Easily  recognized 
in  plates  and  characteristic  of  gall-stones  rather  than  of  mesenteric  glands  or  renal  stones. 
The  difficulty  in  demonstrating  this  type  of  stone  is  mostly  in  the  patient's  breathing  or 
moving;  otherwise  it  can  be  demonstrated  without  difficulty  en  the  plate  or  film. 

PLANCH E  III 

Fig.  6.  Ceci  pouvait  etre  du  a  un  seul  calcul  ou  a  un  amas  compact.  A  ['operation: 
un  calcul. 

Fig.  7.     Rapport  des  ombres  figurees  plus  haut  avec  I'estomac  rempli  de  baryum. 

Fig.  8.  Radiographic  de  la  region  vesiculate  d'une  femme,  montrant  plusieurs 
ombres  annulaires  tres  faibles,  dues  a  des  calculs  bilaires. 

Fig.  0.  Deux  calculs  biliaires  chez  une  femme  de  60  ans.  C'est  la  un  des  types  du 
calcul  a.  couches  concentriques  avec  cortex  riche  en  chaux.  On  les  differencie  aisement 
d'avec  les  ganglions  mesenteriques  ou  les  calculs  du  rein.  Si  I'immobilisation  du  patient  est 
assuree  et  la  respiration  suspendue,  on  doit  pouvoir  mettre  de  tels  calculs  en  evidence. 

PLANCHA  III 

Fig.  6.  Imager  bizarra  de  un  calculo  abundante  en  sales  de  calcio.  Pudo  ser  producida 
tambien  por  un  grupo  compacto;  pero  la  intervencion  quirurgica  demostro  que  no  habia 
mas  que  uno. 

Fig.  7.  El  mismo  caso  de  la  figura  6.  Muestra  las  relaciones  de  dicho  calculo  con  la 
silueta  del  estomago. 

Fig.  8.  Roentgenograma  de  la  region  biliar  de  una  mujer  presentando  varias  soni- 
bras  anulares  muy  tenues  debidas  a  calculos  biliares. 

Fig.  9.  Dos  calculos  biliares  en  una  muier  de  60  aiios.  Son  imagenes  tipicas,  facil- 
mente  reconocibles  y  caracteristicas,  de  calculos  biliares  con  nucleo  de  escasa  densidad  y 
periferia  rica  en  sales  de  calcio.  Se  las  diferencia  sin  trabajo  de  los  ganglios  mesentericos  y 
de  las  piedras  renales.  Los  principales  obstaculos  a  su  demostracion  roentgenografica  son  la 
respiracion  y  los  movimientos  del  enfermo.  Si  ambas  cosas  se  evitan,  el  resultado  satisfacto- 
rio  es  frecuente. 


I'l    Ml 


Fu;.  6. 


Fig.  -. 


Fig.  8. 


Fig.  q. 


PLATI     l\ 


PI.ANCIIb:  IV 


PLANCIIA  IV 


PLATE  IV 

Fig.  io.  Woman,  aged  fifty-five;  weight,  261  pounds.  Two  definite  stones  found  with- 
out difficulty.  At  operation,  2  stones  were  found  the  size  shown  in  the  film  and  several 
smaller  ones  that  were  not  visible  on  the  plate. 

Fig.  11.  Collection  of  small  gall-stones  within  a  small  gall-bladder.  At  the  time  of 
operation  several  surgeons  were  unable  to  palpitate  these  stones  through  the  gail-bladder 
wall.  Under  ordinary  circumstances  the  surgeon  would  not  have  considered  gall-stones, 
illustrating  that  all  gall-bladders  must  be  opened  to  determine  the  presence  or  absence  of 
gall-stones. 

Fig.  12.  Gall-bladder  just  below  the  liver;  small  in  size  but  rather  dense  in  shadow- 
producing  qualities,  suggesting  the  probability  ot  the  pathological  gall-bladder  containing 
stones.  Confirmed  at  operation. 

PLANCHE  IV 

Fig.  10.  Femme  de  55  ans  pesant  119  kilos.  Deux  calculs  facilement  decelables.  A 
P operation  on  en  trouva  d'autres  plus  petits  que  la  radio-graphie  avait  meconnus. 

Fig.  11.  Amas  de  petits  calculs  dans  une  petite  vesicule.  A  I'operation,  plusieurs 
chirurgiens  presents  ne  purent  les  sentir  a  travers  les  parois.  Us  se  seraient  crus  en  droit  de 
nier  leur  presence.  II  laut  done  ouvrir  une  vesicule  si  Ton  veut  etre  sur  de  ee  qu'elle  contient. 

Fig.  12.  La  vesicule  situee  immediatement  sous  le  foie.  Une  ombre  aussi  nette,  en 
depit  de  ses  dimensions  restreintes,  fit  dire  que  la  vesicule  devait  etre  malade  et  contenir 
des  calculs.  Confirmation  operatoire. 

PLANCH  A  IV 

Fig.  10.  Mujer  de  cincuenta  y  cinco  aiios,  que  pesa  261  Iibras.  Dos  calculos  facil- 
mente  reconocibles.  La  operacion  los  encontro  del  mismo  tamano  que  habian  aparecido  en 
la  pelicula  y  ademas  varios  otros  pequeiios  no  sospeehados. 

Fig.  11.  Coleccion  de  pequeiios  calculos  dentro  de  una  vesicula  pcquena.  Durante 
la  operacion  varios  cirujanos  presentes  no  pudieron  sentirlos  a  traves  de  las  paredes  de  la 
vegiguilla.  En  circunstancias  iguales  se  comprende  que  pueda  negarse  su  presencia.  De  ahi 
la  necesidad  de  abrir  siempre  la  vesicula  para  asegurarse  si  contiene  o  no  calculos. 

Fig.  12.  Vesicula  situada  inmediatamente  por  debajo  del  higado.  A  pesar  de  su  exiguo 
tamano,  como  la  sombra  roentgeniana  era  tan  densa,  pensamos  que  se  trataba  de  una 
vesicula  enferma  y  con  calculos.  La  operacion  confirmo  las  sospechas. 


I'l  \l  I   l\ 


Fig.   io. 


Fig.  ii. 


'IG.     12. 


PLATE  V 


PI.ANCIII-.  V 


PLANCHA  Y 


PLATE  V 

Fig.  13.  Illustrates  the  presence  of  gall-stones  in  a  woman,  aged  twenty-three,  and 
also  illustrates,  in  the  absence  of  visible  stones,  that  the  position  of  the  stomach  (plate 
made  in  the  routine  prone  position)  suggests  always  the  possibility  of  fixation  and  pressure 
against  the  antrum  (A),  indicating  the  possibility  of  the  gall-bladder  being  the  cause  of  this 
deformity.  Surgically  proved  to  have  37  small  stones. 

Fig.  14.  Group  of  gall-stones  of  uniform  size  and  density.  Note  dense  peripheral 
shadows  with  very  little  shadow  in  the  nucleus  of  each  stone. 

Fig.  15.  A  well-nourished  individual  showing  two  of  the  common  multiple-faceted 
stones.  Easily  recognized  unless  obscured  by  breathing.  Stones  of  this  type  should  always 
show  on  the  plate  or  film. 

Fig.  16.  Collection  of  small  stones  of  low  atomic  weight,  the  gall-bladder  slightly 
pressing  against  the  antrum  of  the  stomach. 

PLANCHE  V 

Fig.  13.  Calculs  chez  une  femme  agee  de  23  ans.  Le  cliche  demontre  en  plus  que 
I'aspect  de  1'estomac  radiographic  dans  le  decubitus  abdominal  pourrait  suggerer  des  calculs 
merae  si  leur  ombre  etat  absente.  II  est  tiraille  et  I'antre  pylorique,  "A,"  est  deformepar 
une  compression  exterieure.  A  1'operation,  37  petits  calculs. 

Fig.  14.  Un  groupe  de  calculs  biliaires  de  forme  et  de  composition  identiques.  Noter 
que  le  centre  est  beaucoup  plus  transparent  que  la  peripheric 

Fig.  15.  Deux  calculs  d'un  type  tres  commun,  dits  calculs  a  facettes,  radiographics 
chez  un  patient  assez  corpulent.  On  Ies  decelera  assez  facilement  si  Ton  a  soin  d'interdire 
tout  mouvement,  respiratoire  011  autre. 

Fig.  16.  Un  amas  de  petits  calculs  a  poids  atomique  tres  faible.  La  vesicule  deforme 
un  peu  I'antre  pylorique  sur  lequel  elle  appuie. 

PLANCHA  V 

Fig.  13.  Calculos  biliares  en  una  mujer  de  23  anos.  EI  roentgenograma  demuestra 
tambien  que  el  aspecto  y  posicion  del  estomago,  con  el  sujeto  en  decubito  abdominal, 
podria,  aim  en  la  ausencia  de  imagenes  calculares  visibles,  sugerir  el  diagnostico  de  adhe- 
rencias  y  deformacion  del  antro  pilorico  (A)  ocasionadas  por  colecistitis  calculosa.  La  opera- 
cion  descubrio  3^  pequenos  calculos. 

Fig.  14.  Grupo  de  calculos  biliares  de  tamafio  y  densidad  uniformes.  Notese  que  el 
cent m  de  cada  calculo  es  mucho  mas  transparente  que  la  periferia. 

Fig.  15.  Dos  ejemplares  de  una  variedad  de  calculos  muy  comun,  Ilamada  en  lacetas, 
obtenidos  en  sujeto  de  complexion  robusta.  Su  diagnostico  roentgenografico  es  facil,  a  con- 
dicion  de  prohibir  durante  la  exposicion  toda  clase  de  movimiento. 

Fig.  16.  Coleccion  de  calculos  pequenos  y  de  escaso  peso  atomico;  la  vesicula  biliar 
comprime  \  deforma  Iigeramente  el  antro  pilorico. 


'I  \  I  I   \ 


Fig.   13. 


Fig.   14. 


Fig.  t$. 


Fig.  if>. 


PI   Ml    VI 


PLANCH I    VI 


PLANCH A  VI 


PLATE  VI 

Fig.  17.  Collection  of  stones  of  uniform  size  and  density.  Periphery  of  the  stones 
dense.  The  fact  that  there  was  an  increased  density  about  these  stones  was  explained  at 
the  time  of  operation  by  the  density  of  the  bile  in  which  these  stones  were  contained. 

Fig.    18.     Group  of  small  stones;  outline  of  gall-bladder. 

Fig.  19.  Same  case  as  Fig.  18,  showing  barium-filled  stomach,  taken  in  upright  posi- 
tion. The  outline  of  the  gall-bladder  is  clearly  seen.  The  stones  were  contained  in  a  dense, 
dark,  tarry  bile,  the  bile  casting,  relatively,  almost  as  much  shadow  as  the  nuclei  of  the 
stones.  This  case  illustrates:  (1)  that  the  gall-bladder  can  be  visible  with  or  without  stones; 
(2)  that  the  position  of  the  gall-bladder  varies  in  this  instance  with  the  position  ol  the  stom- 
ach when  filled;  (3)  that  the  stomach  is  fixed  more  to  the  right  than  in  a  normal  case. 

PLANCH E  VI 

Fig.  1 7.  Collection  de  calculs  ayant  meme  forme  et  densite.  La  peripheric  est  plus  opaque 
que  le  centre.  Une  ombre  plus  dense  que  les  calculs  semble  Ies  entourer.  Elle  s'expliqua  a 
I'operation  par  la  presence  d'une  bile  tres  epaisse,  plus  opaque  aux  rayons  X  que  Ies  calculs 
eux-memes. 

Fig.    18.     Amas  de  petits  calculs;  vesicule  profilee. 

Fig.  19.  Le  malade  de  la  figure  18,  son  estomac  rempli  de  baryum  et  radiographic 
debout.  La  vesicule  est  bien  visible.  Les  calculs  baignaient  dans  une  bile  epaisse  et  poisseuse 
presqu'aussi  opaque  qu'  eux.  On  voit:  (1°)  que  la  vesicule  est  demontrable,  qu'ellecontienne 
011  non  des  calculs;  (20)  que,  dans  ces  cas,  Iorsqu'on  remplit  l'estomac,  la  vesicule  se  deplace 
avec  Iui;  (30)  que  l'estomac  est  phis  a  droite  qu'il  doit  1'etre. 

PLANCHA  VI 

Fig.  i~.  Coleccion  de  calculos  con  tamaiio  y  densidad  uniformes.  La  periferia  es  mas 
opaca  que  el  centro.  Una  sombra  mas  densa  que  los  calculos  parece  rodearlos.  La  operacion 
probo  que  era  engendrada  por  bills  muy  espesa. 

Fig.   18.     Grupo  de  calculos  pequeiios.  Visible  el  perfil  de  la  vesicula. 

Fig.  19.  El  mismo  caso  de  la  figura  anterior,  pero  con  el  estomago  Ileno  de  bario  y 
el  roentgenograma  de  pie.  El  contorno  de  la  vesicula  se  distingue  netamente.  Los  calculos 
estaban  banados  por  bilis  oscura,  espesa  y  pegajosa  casi  tan  opaca  como  sus  nucleos.  Este 
caso  sirve  para  demostrar:  (1)  que  la  imagen  de  la  vesicula  puede  verse,  contenga  o  qo 
calculos;  (2)  que  en  este  sujeto  la  posicion  de  la  vesicula  varia  con  la  del  estomago  lleno  de 
bario  y  (3)  que  el  estomago  ocupa  un  sitio  mas  hacia  la  derecha  que  en  las  personas  normales. 


PLAT!    \  I 


Fig.   it. 


Fk 


Fig.  19. 


PLAIT  Ml 


PLANCHE  VII 


PLANCH  A  VII 


PLATE  VII 

Figs.  20,  21,  22.  Variety  and  location  of  types  of  stones  found  in  the  study  of  patho- 
logical gall-bladders  which  contain  stones.  They  should  never  be  overlooked,  as  they  are 
always  visible  if  searched  for.  At  times,  unless  due  care  is  taken  in  regard  to  the  breathing 
of  the  patient  during  examination,  one  may  easily  overlook  these  types,  especially  those 
shown  in  Figs.  16  and  21. 

PLANCHE  VII 

Figs.  20,  21,  22.  Divers  types  de  calculs  dans  des  positions  differentes.  On  Ies  decouv- 
rira  toujours  si  Ton  s'en  donne  la  peine.  lis  pourraient  demeurer  invisibles  si  la  respiration 
du  sujet  n'etait  pas  suspendue,  particulierement  ceux  des  figures  16  et  21. 

PLANCHA  VII 

Figs.  20,  21  y  22.  Diferentes  tipos  y  situacion  diversa  de  calculos  coino  suelen  encon- 
trarse  en  el  estudio  de  la  colecistitis  calculosa.  Ordinariamente  visibles,  podrian,  no  obstante, 
pasar  inadvertidos,  si  el  enfermo  no  suspende  la  respiracion  durante  el  examen,  sobre  todo 
Ios  de  Ies  figs.  16  y  21. 


IM.ATI     VII 


Fig.  20. 


Fig.  21 


Fig.  22. 


PLATE  V 


PLANCHE  VIII 


PLANCHA  VIII 


PLATE  VIII 

Fig.  23.  Outline  of  the  pathological  gall-bladder  with  bile  in  one  cf  the  ducts.  One 
can  see  in  this  duct  several  stcnes  of  negative  value,  so  far  as  shadow  is  concerned. 

Fig.  24.  Same  case  as  shown  in  Fig.  23,  three  months  later,  after  repeated  gall-bladder 
attacks.  Duct  empty  at  this  time;  A,  gall-bladder  more  sharply  defined.  At  operation,  a 
gall-bladder  full  of  small  stones  was  found. 

Fig.  25.  A  rather  uncommon  type  of  gall-bladder  full  of  bilirubin  lime  stcnes.  They 
were  found  to  be  very  small  and  so  friable  that  they  were  removed  with  a  good  deal  of 
difficulty. 

Fig.   26.     Three  multiple-faceted  stones. 

PLANCHE  VIII 

Fig.  23.  Profil  d'une  vesicule  malade  et  d'un  des  canaux  rempli  de  bile.  Ce  dernier 
contient  plusieurs  petits  calculs  portant  des  ombres  negatives  c'est-a-dire  plus  transparent^ 
que  leur  entourage. 

Fig.  24.  Meme  malade  (Fig.  23),  3  mois  apres.  II  a  eu  plusieurs  crises.  Cette  fois,  Ies 
canaux  bihaires  sont  vides,  mais  la  vesicule,  "A,"  est  plus  evidente.  A  I'operation  on  la 
trouva  pleine  de  petits  calculs. 

Fig.  25.  Une  vesicule  remplie  de  calculs  a  base  de  bilirubine-chaux.  lis  etaient  si 
petits  et  si  friables  qu'on  cut  du  mal  a  Ies  extraire  sans  Ies  detruire. 

Fig.  26.     Trois  calculs  a  facettes  multiples. 

PLANCHA  VIII 

Fig.  23.  Contorno  de  la  vesicula  enferma  y  de  uno  de  Ios  conductos  Ileno  de  bilis. 
D  entro  del  conducto  hay  varios  calculos  con  imagen  negativa,  es  decir  menos  opaca  que 
la  bilis  circundante. 

Fig.  24.  EI  mismo  caso  de  la  fig.  anterior  3  meses  despues,  durante  Ios  cuales  tuvo 
varios  colicos.  EI  conducto  esta  vacio,  pero  la  vesicula  (A)  es  mas  evidente  y  en  la  operacion 
se  la  encontro  Ilena  de  pequenos  calculos. 

Fig.  25.  Caso  no  frecuente.  Vesicula  Ilena  de  calculos  al  bilirubinate  de  cal.  Eran  tan 
pequenos  y  friables  que  se  extra jeron  con  suma  dificultad. 

Fig.  26.     Tres  calculos  de  facetas  multiples. 


PLAT]    \  III 


Fig.  23. 


Fk;.  24. 


Fig.  25. 


IG.    26. 


PI. A  I  I     IX 


PLANCIIP  IX 


PLANCHA  IX 


PLATE  IX 

Fig.  27.  One  large  gall-stone.  The  gall-bladder  and  the  stone  are  causing  pressure 
against  the  antrum  of  the  stomach.  This  stone  was  not  recognized  in  the  gall-bladder  plates 
or  films  but  was  visible  during  the  barium  meal.  Confirmed  at  operation. 

Fig.  28.  Plate  of  the  gall-bladder  region  in  a  large  woman,  made  with  the  Potter- 
Bucky  diaphragm;  brought  out  more  definitely  than  is  possible  with  the  ordinary  method. 
Calcium  shadows  found  near  the  right  transverse  process  of  the  second  lumbar  vertebra. 

Fig.  29.     One  large  gall-stone. 

PLANCH  E  IX 

Fig.  27.  Un  gros  calcul.  La  vesicule  comprime  I'antre  pylorique.  On  meconnut  ce 
calcul  lors  des  premiers  examens  et  il  ne  fut  decouvert  qu'au  cours  des  examens  au  baryum. 
Confirmation  operatoire. 

Fig.  28.  Cliche  de  la  region  vesiculaire  fait  avec  1'antidiffuseur  Potter-Bucky,  chez 
une  grosse  femme.  Calculs  a  composition  calcaire,  visibles  pres  de  I'apophyse  transverse  de 
la  deuxieme  Iombaire.  L'antidiffuseur  a  donne  dans  ce  cas  des  images  meilleures  que  celles 
possibles  avec  la  technique  ordinaire. 

Fig.  29.     Un  gros  calcul  biliaire. 

PLANCH A  IX 

Fig.  27.  Un  calculo  voluminoso.  La  vesicula  y  la  piedra  comprimen  el  antro  pilorico. 
Paso  inadvertida  en  los  roentgenogramas  directos  de  la  region;  pero  se  le  descubrio  al  llenar 
el  estomago  con  bario.  Confirmado  quirurgicamente. 

Fig.  28.  Placa  de  la  region  biliar  de  una  mujer  corpulenta,  hecha  con  el  antidifusor 
Potter-Bucky.  Calculos  a  base  dc  calcio  visibles  cerca  de  la  apofisis  transversa  de  la  segunda 
lumbar.  El  antidifusor  produjo  imagenes  mejores  que  las  que  hubiera  dado  el  metcdo 
habitual. 

Fig.  29.     Un  calculo  biliar  voluminoso. 


I'l   Ml     l\ 


Fig.  2-. 


Fig.  28. 


Fig.  29. 


PLATE  X 


PLANCHi;  X 


PLANCHA  X 


PLATE  X 

Fig.  30.     One  large  laminated  gall-stone  in  a  woman,  aged  thirty;  removed. 

Fig.  31.  Same  case  as  Fig.  30.  Illustrates  a  plate  made  with  the  same  technique  and 
in  the  same  position  but  in  which  the  stone  was  not  visible,  due  to  the  patient  not  holding 
her  breath.  Illustrates  the  care  that  must  be  used  in  observing  this  one  detail  of  gall-bladder 
examination.  A  stone  as  dense  as  this  one  seems  to  be  in  Fig.  30,  is  not  visible  in  any  way 
in  Fig.  31 ;  it  is  entirely  obliterated  by  motion. 

Fig.  32.  Plate  of  a  large  individual  showing  group  of  small  stones  and  pressure  of  the 
gall-bladder  upon  the  first  portion  of  the  duodenum.  This  is  the  type  of  pressure  defect 
which  should  always  open  the  question  of  a  possible  pathological  gall-bladder  which  may  or 
may  not  contain  stones,  since  it  is  the  only  organ  in  this  region  that  can  produce  a  deformity 
of  this  size  and  shape,  with  the  remote  possibility  of  an  extra  lobe  of  the  liver  or  an  increase 
in  a  portion  of  a  lobe  of  the  liver.  This  plate  is  used  not  so  much  to  show  the  stones  as  to  show 
the  characteristic  effect  of  the  pressure  of  the  gall-bladder  upon  the  first  portion  of  the  duo- 
denum. 

Fig.  33.  Case  referred  as  a  palpable  tumor,  possibly  of  the  proximal  portion  of  the 
transverse  colon  or  hepatic  flexure.  A'-ray  examination  showed  gall-stones  in  a  large  gall- 
bladder with  fixation  of  the  gall-bladder  to  the  bowel.  Condition  confirmed  by  operation 
to  have  been  due  to  a  large  gall-bladder  containing  stones. 

PLANCHE  X 

Fig.  30.  Un  gros  calcul  a  couches  concentriques,  en  pelurc  d'oignon.  Femme  de  30 
ans,  operee. 

Fig.  31.  Mime  cas  (fig.  30).  Ce  cliche  a  etc  fait  dans  la  meme  position  et  avec  la 
meme  technique  que  precedemment.  Mais  le  calcul  est  invisible,  Ie  malade  n'ayant  pas 
suspendu  sa  respiration.  On  voit  I'importance  de  ce  dernier  detail,  puisqu'un  calcul  aussi 
visible  que  celui  de  la  fig.  30  a  pu  s'evanouir  completement. 

Fig.  32.  Cliche  d'un  patient  corpulent  montrant  un  groupe  de  petits  calculs  et  la 
pression  exercee  par  la  vesicule  sur  la  premiere  portion  du  duodenum.  Une  deformation  de  ce 
genre  doit  toujours  faire  soupconner  la  vesicule,  car  elle  seule  peut  la  produire,  l'occurrence 
d'un  lobe  hepatique  hypertrophic  ou  surnumeraire  ctant  \  raiment  exceptionnelle. 

Fig.  33.  Le  malade  avait  une  masse  palpable  dans  1'hypochondre  droit,  qui  pouvait 
bien  etre  une  tumeur  du  colon  a  la  coudure  hepatique  ou  a  la  portion  initiale  du  transverse. 
La  radiographic  montra  des  calculs  dans  une  grosse  vesicule  adherente  a  1'intestin.  Confirma- 
tion operatoire. 

PLANCHA  X 

Fig.  30.     Calculo  de  grandes  dimensiones  y  capas  concentricas  en  una  mujer  de  30 

anos;  opera  da. 

Fig.  31.  EI  mismo  caso  de  la  30.  Roentgenograma  hecho  con  tecnica  y  posicion 
iguales  al  anterior,  pero  el  calculo  es  invisible,  porque  la  enferma  no  suspendio  la  respiracion 
He  ahi  demostrada  la  importancia  de  ese  requisito:  un  calculo  bien  visible  se  esfuma  con  el 
movimiento. 

Fig.  32.  Placa  de  un  individuo  corpulento,  mostrando  un  grupo  de  pequenos  calculos 
v  la  compresion  que  la  vesicula  ejerce  sobre  el  primer  segmento  del  duodeno.  Deformaciones 
como  esta  deben  sugerir  siempre  la  posibilidad  de  una  vesicula  biliar  enlerma,  puesto  que 
es  el  unico  organo  de  la  region  capaz  de  producirla  con  forma  y  tamano  semejantes;  rara 
vez  podran  atribuirse  a  la  prcsion  de  un  lobulo  hepatico  hipertrofiado  o  supernumerario. 
EI  objeto  principal  de  este  roentgenograma  es  el  de  mostrar  esa  caracteristica  deformacion. 

Fig.  33.  EI  enfermo  presentaba  un  tumor  palpable  en  el  hipocondrio  derecho,  que 
bien  podria  ser  un  neoplasma  de  la  acodadura  fiepatica  o  de  la  porcion  inieial  del  colon 
transverso.  EI  examen  roentgenografico  descubrio  calculos  biliares  en  una  vesicula  grande, 
adherida  al  intestino;  y  la  operacion  confirmo  ese  diagnostico. 


PLAT]    \ 


Fie.  30. 


Fig.   ji. 


Fig.  32. 


Fig.  33- 


PLATE  XI 


PLANCHE  XI 


PLANCH A  XI 


PLATE  XI 

Fig.  34.  Case  referred  for  probable  gall-stones.  Plates  showed  a  group  of  small 
shadows  unquestionably  due  to  calcium.  Diagnosis:  Probable  collection  of  small  stones. 
Operation:  Drainage  of  gall-bladder;  no  evidence  of  the  stones.  Plates  made  several  weeks 
after  operation  showed  no  evidence  of  these  shadows.  Conclusion:  Either  these  stones  were 
being  passed  through  one  of  the  ducts  at  the  time  of  the  x-ray  examination,  or  they  were 
lost  during  drainage. 

Fig.  35.  Palpable  tumor  in  upper  right  quadrant,  in  an  elderly  woman,  found  to  be 
due  to  3  large  gall-stones  and  several  small  ones.  This  plate  illustrates  the  size,  position, 
and  pressure  of  the  gall-bladder  upon  the  colon,  which  one  occasionally  observes. 

Fig.  36.     One  stone  of  unusual  shape,  and  of  more  or  less  uniform  density. 

Fig.  3".  Group  of  small  stones  with  very  little  calcium,  showing  as  much  of  the  out- 
line of  the  gall-bladder  as  of  the  stones.  Extremely  low  penetration  is  necessary  to  make  these 
stones  visible. 

PLANCHE  XI 

Fig.  34.  Diagnostic  clinique:  Cholelithiase  probable.  La  radiographic  montra  un 
groupe  de  petites  ombres  evidemment  dues  a.  de  la  chaux.  On  en  conclut  a  la  presence  proba- 
ble de  calculs.  La  vesicule  fut  cuverte,  on  n'y  trouva  pas  de  calculs  et  on  la  draina.  Des 
cliches  pris  plusieurs  semaines  apres  ne  portaient  plus  Ies  ombres  suspectes.  II  faut  conclure 
que  Ies  calculs  etaient  en  voie  d'expulsion  lors  de  la  radiographic  ou  bien  qu'ils  sont 
passes  inappercus  dans  Ies  pansements. 

Fig.  35.  Masse  palpable  dans  1'hypochondre  droit  chez  une  vieille  femme.  Elle 
etait  due  a  trois  gros  calculs  biliaires  et  plusieurs  petits.  Le  cliche  montre  la  forme  et  la 
position  de  la  vesicule  amsi  que  la  pression  sur  le  colon  qu'elle  exerce  parfois. 

Fig.  36.     Un  calcul  non  homogene;  sa  forme  est  exceptionnelle. 

Fig.  37.  Groupe  de  calculs  pauvres  en  chaux.  lis  ne  sont  pas  plus  visibles  que  Ies 
parois  de  la  vesicule. 

PLANCH A  XI 

Fig.  34.  Diagnostico  clinico:  probable  colehtiasis.  La  radiografia  demuestra  un  grupo 
de  pequenas  sombras,  producidas  evidentemente  per  sales  de  cal.  Diagnostic!  roentgeno- 
Iogico:  probable  coleccion  de  pequenos  calculos.  A  la  operacion  no  se  encontraron  calculos 
y  se  dreno  la  vesicula.  Placas  tomadas  varias  semanas  despues  no  contenian  ya  las  sombras 
sospechosas.  Es  includable  que,  una  de  dos,  o  Ios  calculos  seexpulsaron  inmediatamente 
despues  del  primer  examen  roentgenologico  o  pasaron  inadvertidos  en  el  drenaje. 

Fig.  35.  Tumor  palpable  en  el  hipocondno  derecho  de  una  vieja.  Era  debido  a  tres 
gruesos  calculos,  acompanados  de  vanos  pequenos.  Esta  placa  demuestra  el  tamano,  posi- 
cion  y  compresion  de  la  vesicula  sobre  el  colon,  segun  se  observa  a  veces. 

Fig.  36.     Un  calculo  de  forma  bizarra  y  de  extructura  irregular. 

Fig.  3".  Grupo  de  pequenos  calculos  pobres  en  calcio,  no  mas  visibles  que  el  con- 
torno  de  la  vesicula.  Para  obtener  su  imagen  es  necesario  usar  una  ampolla  blanda. 


II  \ II-:  xi 


Fig.  34. 


Fig.   15. 


Fig.  36. 


Fig.   3" 


PLATE  XII 


planchl  xii 


PLANCH  A  XII 


PLATE  XII 

Fig.  38.     Three  small  stones. 

Fig.   39.     One  large  stone.  Note  the  irregular  outline  of  the  peripheral  shadow. 

Fig.  40.  Gall-bladder  area  of  a  woman  with  roentgen  diagnosis  of  probable  stones. 
A  dense  shadow,  uniform  in  quality,  was  found  over  the  edge  of  the  vertebrae.  Surgically, 
proved  to  be  a  pancreatic  stone,  the  pancreas  containing  several  stones.  (See  Fig.  41  for 
lateral  view.) 

Fig.  41.  Same  case  as  shown  in  Fig.  40.  Lateral  view  showing  the  position  of  the 
stone  in  relation  to  the  duodenum  and  the  posterior  wall  of  the  stomach.  A,  stone;  B, 
pylorus.  Stones  not  removed  at  operation.  Gall-bladder  removed  and  fcund  pathological. 

PLANCHE  XII 

Fig.   38.     Trois  petits  calculs. 

Fig.  39.     Un  gros  calcul;  noter  l'aspect  irregulier  de  son  contour. 

Fig.  40.  Region  vesiculate  d'une  femme  suspecte  de  Iithiase  biliaire.  Une  tache 
opaque  recouvre  le  rebord  de  la  vertebre.  L'operation  decouvrit  un  calcul  du  pancreas. 
(Voir  aussi  la  figure  41.) 

Fig.  41.  Le  raeme  calcul  (Fig.  40),  en  Iaterale.  On  voit  sa  position  relativement  a  la 
paroi  posterieure  de  1'estomac  et  au  duodenum.  A,  calcul. — 5,  pylore.— On  laissa  Ies 
calculs  du  pancreas;  la  vesicule  etant  malade,  on  1'extirpa. 

PLANCH  A  XII 

Fig.  38.     Tres  calculos  pequeiios. 

Fig.  39.     Calculo  voluminoso  de  contorno  irregular. 

Fig.  40.  Region  biliar  de  una  mujer  con  diagnostico  roentgenologico  de  probable 
colelitiasis.  Una  sombra  de  uniforme  y  marcada  densidad  cubre  el  reborde  de  la  vertebra. 
La  operacion  demostro  que  se  trataba  de  un  calculo  del  pancreas  que,  ademas,  contenia 
otros.  (Vease  fig.  41,  imagen  lateral.) 

Fig.  41.  EI  mismo  caso  de  la  fig.  40.  Vista  lateral  ensenando  la  posicion  de  la  piedra 
en  relacion  con  el  duodeno  y  la  pared  posterior  del  estomago.  A,  calculo;  B,  poloro.  No 
se  extrajeron  los  calculos  pancreaticos,  pero  se  extirpo  la  vesicula  enferma. 


PLATE  XII 


Fig.  38. 


Fig.  39. 


Fig.  40. 


Fig.  41. 


THE  VISIBLE  PATHOLOGICAL  GALL-BLADDER 

Plates  XIII  to  XXIV  are  used  to  illustrate,  so  far  as  possible,  the  vari- 
ous types  of  pathological  gall-bladder  that  one  meets  with  in  studying  a  series 

of  cases,  and  are  chosen  to  illustrate  various  sizes,  shapes,  and  positions  ol 
the  gall-bladder.  The  mere  study  of  a  series  of  films  showing  a  visible  gall- 
bladder is  not  so  important  as  using  the  complete  set,  including  tin-  barium 
meal.  In  almost  every  instance  of  a  definite  pathological  gall-bladder,  we 
shall  observe  either  indirect  or  secondary  changes.  Unfortunately,  it  is 
not  possible,  in  every  instance,  to  add  to  the  series  of  gall-bladder  plates 
the  accompanying  barium  meal  films. 

The  errors  that  arise  in  the  stud\  of  tin-  visible  gall-bladder  occur  in 
selecting  the  shadow  which  is  produced  by  the  gall-bladder.  The  commonest 
source  of  error  is  the  visible  kidney  outline.  For  some  reason  not  clear  to  the 
writers,  the  kidney  becomes,  m  certain  cases  (m  the  female  especially),  vcr\ 
definitely  visible,  sometimes  in  an  unusual  position,  and  occasionally  a 
portion  of  the  kidney  will  show,  as  the  upper  pole  or  the  lower  pole,  or  one  ol 
its  borders,  or  a  high  kidney  will  be  seen.  These  conditions  may  lead  one  to 
suspect  the  shadow  as  being  due  to  the  gall-bladder.  It  would  seem  possible, 
in  every  instance,  to  show  the  kidney,  but  it  has  not  been  the  experience  ol 
the  writers  that  even  in  a  very  carefully  exposed  series  ol  films  has  this 
always  been  possible.  Occasionally,  with  what  is  apparently  the  clearest  and 
most  visible  gall-bladder,  one  may  be  in  error,  since  this  shadow  may  be  the 
stomach  full  of  the  ordinary  food  meal  or  liquids.  Again,  postoperative  gall- 
bladder cases  will  sometimes  reveal,  even  alter  the  removal  ol  the 
gall-bladder,  shadows  that  are  similar  in  size,  shape  and  position  to  the 
gall-bladder;  and  w  c  have  found  surgically,  that  in  some  instances  this  is  due 
to  omental  fat  which  has  accidentally  given  us  a  shadow.  Again,  extra  lobes 

of  the  liver,  as  a  caudate  or  RicckTs  lobe,  will  give  us  a  very  definite  shadow 

87 


PLATE  XIII 

The  arrows  point  to  a  visible  gall-bladder  overlying  the  upper  pole  of  the  kidney. 
This  is  the  type  of  a  pathological  gall-bladder  which  by  its  size,  shape  and  position  will 
cause  pressure  either  upon  the  first  portion  of  the  duodenum,  or  the  antrum  of  the 
stomach,  or  the  second  portion  of  the  duodenum. 

PLANCHE  XIII 

La  fleche  signale  une  vesicule  visible  recouvrant  Ie  pole  superieur  du  rein.  Cest  la  le 
type  d'une  vescule  pathologique  pouvant,  par  ses  dimensions  sa  forme  et  sa  position, 
exercer  une  pression  soit  sur  la  premiere  portion  du  duodenum,  soit  sur  I'antre  pylorique, 
soit  sur  la  seconde  portion  du  duodenum. 

PLANCH  A  XIII 

Las  flechas  indican  la  imagen  de  la  vesicula  sobrequesta  a  la  del  polo  superior  del 
rinon.  Es  el  tipo  de  vesicula  biliar  enferma  que,  por  su  tamano,  forma  y  posicion,  corn- 
prime  y  deforma  el  bulbo  duodenal,  el  antro  pilorico  o  la  segunda  porcion  del  duodeno. 


GEORGE  6?  LEONARD— GALL-BLADDER 


''I  ATF.  >'HI 


ANNALS  OF 
ROENTGENOLOGY,  VOL.  II. 


PUBLISHED  BY 
PALL  B.  HOEBER.  N.  Y 


PATHOLOGICAL  GALL-BLADDERS  89 

that  one  might  mistake  for  a  gall-bladder.  This  special  condition  must  always 
be  kept  in  mind;  it  is  in  these  cast's,  as  in  all  cases,  that  the  indired  or  second- 
ary signs  make  the  diagnosis  more  definite  or  less  so.  Fecal  matter  in  the 

hepatic  colon  or  proximal  portion  of  the  transverse  colon  may,  unless  the 
films  arc  carefully  studied,  be  mistaken  Tor  a  shadow  suggestive  ol 
the  gall-bladder. 


&* 


LA  VESICULE  VISIBLE 

Les  planches  XIII  a  XXIV  qui  suivent  ont  etc  choisies  pour  illustrer, 
autant  epic  possible,  les  divers  types  de  vesicule  pathologiques  el  les 
varietes  de  calculs  qu'on  pent  rencontrer.  La  simple  lecture  d'une  serie  de 
plaques  ou  se  montre  la  vesicule  est  moms  utile  epic  ['etude de  tout  1111  jeu  de 
plaques  ou  figure  aussi  I'estomac  rempli  de  baryum.  Dans  presque  tons  les 
cas  ou  la  vesicule  est  visible,  no  pourra  observer  des  symptomes  second- 
aires  ou  mdirects.  Malheureusement  il  n'est  pas  toujours  possible  de 
completer  les  examens  de  la  vesicule  par  I'examen  gastro-intestinal. 

En  recherchant  ['image  de  la  vesicule  on  est  expose  a  certaines  con- 
tusions. L'ombre  qui  prete  le  plus  aux  meprises  est  celle  du  rein.  Pour  des 
raisons  epic  nous  ignorons,  le  rein  pent  etre,  surtout  chez  la  femme,  tres 
visible;  il  apparaitra  dans  une  position  msolite,  parlois  ties  haut.  Ou  encore 
on  tie  vena  qu'une  partie  de  son  contour,  Tun  ou  "autre  de  ses  poles  ou  son 
rebord.  II  serait  facile  de  prendre  une  telle  image  pour  la  vesicule.  II  n'esl  pas 
toujours  possible,  dans  ['experience  des  auteurs,  de  montrer  tout  le  rem, 
meme  en  multipliant  les  cliches.  Parlois  le  contenu  solide  ou  liquide  de 
I'estomac  pent  donner  le  change.  Chez  un  malade  dont  la  vesicule  a  etc 
extirpee  on  trouvera  des  ombres  qui  semblent  dues  a  I'organe  absent. 
L'exploration  chirurgicale  nous  a  montre  epic,  dans  ces  cas,  "ombre  pro'V  enah 
des   masses  graisseuses  de  ['epiploon.   Enfin,  des  lobes  h&patiques,     lobes 


90  PATHOLOGICAL  GALL-BLADDERS 

caudes  ou  de  Riedel, — peuvent  simuler  la  vesicule.  On  devra  toujours  penser 
a  ccs  causes  d'erreur  et  ne  pas  negliger,  pour  etayer  Ic  diagnostic,  Ics  indices 
accessoires.  Bien  entendu,  des  matieres  fecales,  a  I'anse  hepatique  ou  dans  la 
premiere  portion  du  colon,  sont  capables  dc  fournir  des  images  semblables 
a  cdles  de  la  vesicule. 

IMAGEN  ROENTGENIANA  DE  LA  VESICULA 
BILIAR  ENFERMA 

Los  clises  XIII  y  XXIV  se  eligieron  con  el  proposito  de  ilustrar,  en  todo 
Io  posible,  Ios  diversos  tipos  de  vesicula  biliar  enferma  y  las  situaciones  dis- 
tmtas  en  que  el  investigador  puede  eueontrar  la  cuando  estudie  un  grupo  de 
casos.  La  mera  lectura  de  una  serie  de  peliculas  en  cjue  sc  muestre  la  vesicula 
no  tiene  tanta  importancia  como  el  estudio  de  un  juego  completo,  que  in- 
cluya  la  imagen  del  estomago  Ilcno  dc  bario.  En  casi  todos  Ios  casos  de 
enfermedad  de  la  vesicula  biliar  se  observaran  sintomas  indirectos  o  secun- 
darios.  Por  desgracia,  no  siempre  es  posible  completar  el  examen  de  las  vias 
bihares  con  el  del  tubo  digestive 

Los  errores  que  se  cometen  en  el  estudio  de  la  vesicula  biliar  dependen, 
en  su  mayor  parte,  de  una  equivocada  seleccion  de  la  sombra  que  ha  de 
corresponderle  en  la  placa.  La  causa  mas  frecuente  de  error  es  el  rinon  dere- 
cho,  cuya  sombra,  por  razones  que  ignoramos  todavia,  se  muestra  en  cicrtos 
casos,  pero  sobre  todo  en  las  mujeres,  claramente  visible,  apareciendo,  unas 
veces,  en  posicion  insolita,  algunas,  situado  muy  arriba  y  otras,  destacando 
solamente  la  silueta  dc!  reborde  o  de  uno  de  sus  polos,  bien  sea  el  inferior  o 
ya  el  superior;  circunstancias  todas  que  favorecen  la  confusion  de  estas 
sombras  con  las  de  la  vesicula  biliar,  tanto  mas  cuanto  que,  segun  nuestra 
experiencia,  no  es  posible,  ni  aim  multiplicando  Ios  clises,  obtener  en  todos 
Ios  casos  la  imagen  total  del  rinon.  A  veces  podria  tomarse  por  la  sombra 
de  una  vesicula  bien  visible  Io  que  no  es  otra  cosa  que  el  estomago  Ilcno  de 


PA  I  HOI  OGICAL  GA]  L-BLADDERS  91 

li(|uiclo  0  de  materiales  alimenticios.  IVIas  todavia;  un  operado  de  colecis- 
tectomia  puede  mostrar,  algun  tiempo  despues,  en  la  region  Dinar  sombras 
similares,  porsu  tamano,  forma  \  posicion  a  la  de  la  vesicula;  \  sin  embargo, 
la  experimentacion  quirurgica  nos  ha  demostrado  que,  en  ciertos  casos, 
dichas  imagenes  son  producidas  por  masas  grasosas,  epiploicas.  Ademas, 
algunos  lobulos  accesorios  del  higado,  como  el  lobulo  caudado  0  <!<■  Riedel, 
suelen  proyectar  sombras  confundibles  con  las  vesiculares;  \  pur  ultimo, 
tambien  originan  imagenes  parecidas  [os  rrsiduos  IccaUs  in  la  at-ndadura 
hepatica  del  colon  0  v\i  la  primera  porcion  cU-  su  segmento  transverse  I  ales 
causas  de  error  no  deben  descuidarse,  puesto  que  se  entonces  c|iu-  cl  estudio 
metodico  de  [os  signos  indirectos  0  secundarios  constituye  un  auxiliar  pod- 
eroso  para  el  esclarecimiento  eld  diagnostics 


PLATE  XIV 


PLANCHE  XIV 


PLANCHA  XIV 


PLATE  XIV 

Fig.  42.  Woman,  aged  forty.  Two  definite  shadows  in  the  upper  right  quadrant, 
outlined  on  plate  with  arrows.  The  upper  shadow  is  consistent  with  the  kidney;  the  lower 
by  its  size  and  shape  is  consistent  with  the  gall-bladder.  At  operation,  a  gall-bladder  more 
of  the  size  and  shape  of  the  upper  shadow  was  found.  There  were  no  secondary  changes 
except  the  very  high  position  of  the  hepatic  flexure,  and  about  the  hepatic  flexure  were  very 
fine,  indefinite  adhesions  which  extended  to  the  under  surface  of  the  liver  and  near  the  gall- 
bladder. It  is  our  opinion  that  the  lower  shadow  was  the  gall-bladder;  the  upper,  that  of  a 
high  kidney. 

Fig.  43.  Man,  aged  forty-five.  Definite  outline  of  the  gall-bladder  (A)  overlying  the 
upper  pole  of  the  kidney.  Within  the  shadow  of  the  gall-bladder  two  areas  are  seen  which 
proved  at  operation  to  be  2  stones  that  did  not  cast  any  shadow.  One  stone  is  shown  in  the 
common  duct  (B). 

Fig.  44.  Outline  of  the  gall-bladder  in  a  large  man.  No  stones  were  found  at  operation, 
but  dark,  tarry  bile.  There  were  no  definite  indirect  or  secondary  manifestations. 

PLANCHE  XIV 

Fig.  42.  Femme  de  40  ans.  Deux  ombres  nettes  dans  I'hypochondre,  indiquces  par 
des  fleches.  L'ombre  superieure  peut  se  rapporter  au  rein;  1'inferieure,  par  sa  forme  et  ses 
dimensions,  a  la  vesicule.  A  1'operation  on  trouva  une  vesicule  correrpondant  plutot  a 
l'ombre  superieure.  Rien  d'autre,  si  ce  n'est  que  1'anse  hepatique  etait  tres  haut,  et  qu'autour 
d'elle  il  y  avait  des  adherences  tres  fixes  s'etendant  sous  le  foie  et  dans  le  voisinage  de  la 
vesicule.  Nous  croyons  que  l'ombre  superieure  etait  bien  celle  de  la  vesicule  et  l'autre,  celle 
d'un  rein  haut-situe. 

Fig.  43.  Homme  de  45  ans.  Vesicule  nettement  dessinee  en  A,  recouvrant  le  pole 
superieur  du  rein.  Dans  Ies  Iimites  de  l'ombre  portee  par  la  vesicule,  deux  ilots  que  1'opera- 
tion demontra  etre  des  calculs.  Un  calcul,  B,  est  dans  le  canal  choledoque. 

Fig.  44.  Vesicule  visible  chez  un  homme  corpulent.  On  trouva  une  vesicule  remplie  de 
bile  poisseuse,  sans  calculs.  Pas  de  manifestations  secondaires. 

PLANCHA  XIV 

Fig.  42.  Mujer  de  40  afios.  Dos  sombras  netas  eu  el  hipocondrio  derecho,  seiialadas 
en  el  clise  por  flechas:  la  superior  parece  corresponder  al  rinon;  la  inferior  se  parece,  por  la 
forma  y  tamano,  a  la  de  la  vesicula.  La  operacion  descubrio  una  vesicula  de  aspecto  semc- 
jante  a  la  sombra  superior.  No  habia  otras  alteraciones  secundarias  que  la  posicion  elevada 
del  codo  hepatico  del  colon  y  la  presencia  a  su  alrededor  de  finas  adherencias  extendidas  a 
la  cara  inferior  del  higado  y  en  la  vecindad  de  la  vesicula.  Nosotros  creemos,  sin  embargo, 
que  la  sombra  inferior  correspondia  a  la  vesicula  y  la  superior  a  un  rinon  situado  muy 
arriba.  He  ahi  un  ejemplo  de  Io  dificil  que  suele  ser  el  reconocimiento  de  la  sombra  vesicular. 

Fig.  43.  Hombre  de  45  afios.  Contorno  bien  definido  de  la  vesicula  (A)  sobrepuesto 
al  polo  superior  del  rinon;  dentro  de  la  imagen  de  la  vesicula  se  ven  dos  areas,  que  la  opera- 
cion demostro  ser  dos  calculos  que  no  habian  dado  sombras  precisas.  Uno  de  ellos  se  encon- 
traba  en  el  coledoco  (B). 

Fig.  44.  Contorno  de  la  vesicula  en  un  hombre  corpulento.  La  operacion  no  descu- 
brio calculos,  sino  bilis  oscura  y  espesa.  No  habia  tampoco  manifestaciones  indirectas  o 
secundarias. 


H   VI  E   \l\ 


Fig.  42. 


1 


Fie.  43. 


Fig.  44. 


PLATE  XV 


hi  WCIII    w 


PIANCHA  XV 


PLATE  XV 

Fig.  45.  Woman,  aged  twenty-three.  Definite  outline  of  the  gall-bladder.  Shadow 
dense  in  character,  the  shape  and  size  of  the  gall-bladder. 

Fig.  46.  Same  ease  as  shown  in  Fig.  45,  showing  pressure  on  the  duodenum.  It  is  of 
interest  to  note  that  in  plates  or  films  of  the  stomach  made  with  more  penetration  than 
would  be  used  in  gall-bladder  examination,  we  lose  the  outline  of  the  gall-bladder  but  see 
the  effect  of  the  gall-bladder  upon  the  first  portion  of  the  duodenum.  This  case  illustrates 
the  necessity  of  extreme  care  in  exposures  taken  to  determine  the  visible  gall-bladder. 
Operation  showed  no  evidence  of  stones.  Extremely  dark  bile. 

Fig.  4~.  Woman,  aged  forty,  with  indefinite  clinical  symptoms.  Plates  of  the  gall- 
bladder region  showed  a  visible  gall-bladder. 

Fig.  48.  Same  case  as  illustrated  in  7.  Fig.4  Lateral  view,  showing  the  pressure  of 
this  mass  upon  the  beginning  of  the  second  portion  of  the  duodenum.  At  operation,  the 
pathological  gall-bladder  with  fixation  to  the  duodenum  was  found. 

PLANCHE  XV 

Fig.  45.     Femme  de  23  ans.  L'ombre,  bien  evidente,  est  caracteristique  de  la  vesicule. 

Fig.  46.  Meme  malade  (fig.  45).  On  voit  la  pression  exercee  sur  le  duodenum.  II  est 
interessant  de  noter  que,  dans  les  cliches  faits  de  I'estomac,  avec  des  rayons  relativement 
penetrants,  la  vesicule  s'evanouit;  mais  son  effet  sur  le  duodenum  se  montre  quand  meme. 
On  voit  quel  som  il  laut  v  mettresi  Ton  veut  pouvoir  montrer  le  vesicule.  A  I'operation: 
bile  tres  lonccc,  sans  calculs. 

Fig.  4".  Femme  de  40  ans,  avec  symptomes  cliniques  vagues.  La  vesicule  est  visible 
sur  les  radios. 

Fig.  48.  Meme  cas  (fig.  47).  La  vue  laterale  montre  la  pression  exercee  sur  le  com- 
mencement de  la  seconde  portion  du  duodenum.  A  I'operation:  vesicule  malade,  fixee  au 
duodenum. 

PLANCHA  XV 

Fig.  45.  Mujer  de  25  anos.  Contorno  vesicular  bien  defimdo.  Es  una  imagen 
caracteristiea. 

Fig.  46.  El  mismo  caso  anterior,  mostrando  la  compresion  del  duodeno.  Es  interesante 
observar  que  en  los  clises  del  estomago  hechos  con  una  ampolla  mas  dura  que  las  empleadas 
para  el  examen  de  la  vesicula  la  imagen  de  este  ultimo  organo  desaparece,  pero  se  nota  el 
efecto  de  su  presion  sobre  el  primer  segmento  del  duodeno.  Vease,  pues,  cuanto  cuidado 
necesitan  Io  roentgenogramas  que  muestran  la  imagen  de  la  vesicula.  La  operacion  solo 
descubrio  bilis  oscura,  sin  calculos. 

Fig.  4".  Mujer  de  40  anos,  con  sintomas  clinicos  indefmidos.  Vesicula  visible  en  los 
clises. 

Fig.  48.  EI  mismo  caso  de  la  fig.  4".  Vista  lateral.  Observese  la  compresion  sobrela 
poreion  inicial  del  segundo  segmento  del  duodeno.  En  la  operacion  se  encontro  la  vesicula 
adherida  al  duodeno. 


I'l   \l  I     w 


/ 


Fig.  45. 


Fig.  46. 


Fig.  47. 


PLATE  XVI 


PLANCHE  XVI 


PLANCH  A  XVI 


PLATE  XVI 

Fig.  49.  Distinct  shadows,  unquestionably  clue  to  calcium.  These  shadows  indicate 
stones  in  the  gall-bladder  and  possibly  in  the  duct,  judging  partly  from  their  unusual  shape 
and  partly  from  their  unusual  position.  This  is  particularly  well  emphasized  in  the  lateral 
view  1  not  given  here),  which  shows  shadows  to  be  in  the  position  of  the  normal  gall-bladder 
and  not  in  the  position  of  the  normal  kidney. 

Fig.  50.  Same  case  as  illustrated  in  Fig.  49.  Shows  the  shadows  in  relation  to  the  first 
and  second  portions  of  the  duodenum,  which  knowledge  helps  to  confirm  the  probability 
of  these  being  stones  within  the  gall-bladder  or  duct.  The  lateral  view  shows  these  shadows 
to  be  in  the  position  ot  the  normal  gall-bladder,  in  relation  to  the  normal  kidney  position. 
At  i  iperation,  4  rounded  stones  were  found  in  the  gall-bladder,  the  largest  an  inch  in  diameter. 
Two  elongated  stones  were  found  in  the  common  duct.  The  gall-bladder  was  adherent  to  the 
under  surface  of  the  liver,  but  there  were  no  adhesions  involving  the  other  organs. 

Fig.  51.  Visible  gall-bladder  with  fixation  of  the  stomach.  The  shadow  was  found 
only  through  the  series  of  stomach  plates. 

PLANCH  E  XVI 

F:g.  49.  Ombres  tres  nettes,  evidemment  dues  a  de  la  chaux.  Files  denotent  des 
caiculs  dans  la  vesicule,  et  aussi  dans  les  canaux  biliaires,  si  Ton  en  |uge  par  la  forme  et  les 
dimensions  anormales  de  certaines  ombres.  Une  radiographic  en  Iaterale,  que  nous  ne 
reproduisons  pas  ici,  montre  qu'il  faut  tout  rapporter  a  la  vesicule  et  non  au  rein. 

Fig.  50.  Fe  cas  precedent  (fig.  49).  On  voit  Ie  rapport  des  ombres  suspectes  avec  les 
deux  premieres  portions  du  duodenum.  Ceci  incline  davantage  a  penser  qu'il  s'agit  de  caiculs 
de  la  vesicule  et  des  canaux.  Fes  rapports  avec  le  rein  sont  normaux.  A  I'operation :  4  caiculs 
arrondis  dans  la  vesicule,  le  plus  gros  ayant  25  mms.  de  diametre.  Deux  caiculs  effiles  dans 
Ie  canal  choledoque  Rien  d'autre  a  part  1'adherence  de  la  vesicule  a  la  face  inferieure  du  foie. 

Fig.  51.  Vesicule  visible,  estomac  fixe.  On  ne  trouva  fa  vesicule  qu'au  cours  de  la 
serie  gastrique. 

PLANCHA  X\  I 

Fig.  49.  Sombras  evidentes,  de  includable  origen  calcico  Indican  calculos  en  la  vesicula 
v  probablemente  en  el  conducto,  si  se  juzgan  por  su  forma  y  situacion  anormales.  Esto  se 
nota  mejor  en  la  vista  lateral  (no  mostrada  aqui)  que  presenta  dichas  sombras  en  la  region 
de  la  vesicula  >   no  en  la   renal. 

Fig.  50.  El  mismo  de  la  figura  49.  Veanse  las  relaciones  de  las  sombras  sospechosas 
con  las  dos  primeras  porciones  del  duodeno,  nocion  que  viene  a  reforzar  el  diagnostic*  > 
probable  de  calculos  de  la  vesicula  y  conduct  us  biliares.  Fa  vista  lateral  demuestra  que  las 
relaciones  con  el  rinon  son  normales.  La  operacion  descubrio  4  piedras  redondas  en  la  vesi- 
cula, una  de  ellas  midiendo  2^  milfmetros  cle  diametro;  y  dos  alargadas  en  el  coledoco.  La 
vesicula  adheria  a  la  cara  inferior  del  higado.  No  habia  otras  adherencias. 

Fig.  51.  Vesicula  visible  adherida  al  estomago.  Solo  pudo  demostrarse  durante 
el  examen  con  desayuno  opaco. 


PLAT!    W  I 


Fig.  49. 


Fig.  50. 


Fig.  51. 


PLATE  \\  II 


PLANCIII".  XVII 


PLANCHA  XVII 


PLATE  XVII 

Fig.  52.  Large  visible  pathological  gall-bladder  containing  calcium  shadows.  (It  will 
be  noted  that  the  lines  of  the  gown  the  patient  wore  are  shown.)  This  case  illustrates  the 
extreme  care  on  exposure  that  was  necessary  to  bring  out  the  outline  of  this  gall-bladder. 
I  echnically,  the  difficulty  in  making  this  examination  was  the  over-penetration  which  would 
obscure  the  outline  of  the  gall-bladder.  It  was  only  when  using  a  very  low  spark  gap,  very 
high  milliamperage  and  a  very  rapid  exposure,  with  forced  development,  that  we  could  get 
the  outline  of  this  gall-bladder. 

Fig.  53.  Woman,  aged  fifty,  showing  a  visible  gall-bladder  containing  only  dense, 
tarry  bile. 

Fig.  54.  Woman,  aged  twenty-eight,  operated  upon  for  chronic  cholecystitis  several 
years  previous;  drained.  Complete  recovery.  Return  of  symptoms  prior  to  this  examination. 
Roentgen  films  showed  visible  gall-bladder  with  fixation  ol  the  stomach  in  the  area  of  the 
shadow.  Operation  confirmed  roentgen  findings 

Fig.   55.     Visible  gall-bladder.  Surgically:  Chronic  cholecystitis,  without  stones. 

PLANCH E  XVII 

Fig.  -,"2.  Crosse  vesicule  visible  encadrant  des  ombres  calcaires.  On  peut  juger  du 
soin  qu'il  fallut  apporter  a  la  technique  par  la  presence  des  ombres  vestimentaires.  Un  ray- 
onnement  dur  cut  efface  Ie  profil  de  la  vesicule.  Seuls  un  rayonnement  tres  mou,  avec  fort 
courant  et  breve  exposition  purent  la  mettre  en  ex  idence. 

Fig.  53.  Femme  de  50  ans;  sa  vesicule,  visible,  ne  contenait  cjue  de  la  bile  epaissc, 
poisseuse. 

Fig.  54.  Femme  de  28  ans  operee  plusieurs  annees  auparavant  pour  cholecystite. 
Guerison  complete  apres  drainage.  Reapparition  des  troubles.  A  la  radio,  vesicule  xisible 
avec  estomac  fixe  clans  les  limites  de  ['aire  vesiculaire.  Confirmation  operatoire. 

Fig.   ,-,".     Vesicule  \  isible.  A  ('operation:  cholecystite  chronique  non-calculeuse. 

PLANCHA  XVII 

Fig.  -,"2  Voluminosa  vesicula  conteniendo  sombras  calcareas.  La  presencia  en  el 
clise  de  algunas  imagenes  vestimentarias  da  clara  idea  de  la  delicadeza  de  tecnica  necesaria 
para  demostrar  la  vesicula:  empleando  rayos  duros  no  se  hubiera  obtenido  su  imagen, 
mientras  que  el  exito  lue  posible  con  una  breve  exposition  a  rayos  muy  blandos  y  gran 
miliamperaje.  Hubo  necesidad  tambien  de  forzar  el  desarrollo. 

Fig.  53.     Mujer  de  50  anos,  mostrando  una  vesicula  Ilena  de  bilis  espesa  y  pegajosa. 

Fig.  54.  Mujer  de  28  anos,  operada  varios  anos  antes  por  colecistitis  cronica.  Drenaje 
de  la  vesicula  y  curacion  immediata.  Reaparicion  de  los  sintomas  y  necesidad  de  un  niievo 
examen.  El  roentgenograms  demostro  'la  vesicula  xisible  y  el  esti'nnago  arrastrado.  \  fijo 
por  adherencias  a  la  sombra  vesicular.  La  operacion  confirmo  el  diagnostico. 

Fig.   si-     Vesicula  xisible.  A  la  operacion,  colecistitis  cronica  no  calculosa. 


I'l   \l  I     w  I 


Fig.   52. 


Fig.   53. 


A 


Fig.   54. 


Fig.   55. 


PLATF,  Will 


PLANCHK  Will 


PLANCH  A  Will 


PLATE  XVIII 

Fig.  56.  Delinite  shadow  in  the  region  of  the  gall-bladder.  Roentgen  diagnosis: 
Probable  pathological  gall-bladder  which  may  or  may  not  contain  stones.  Surgically : 
Moderately  dilated  gall-bladder  full  of  calcium  bilirubin  stones. 

Fig.  57.  Visible  gall-bladder  in  a  case  apparently  similar  to  the  case  shown  in  Fig.  56, 
but  containing  pure  bilirubin  lime  stones  in  large  numbers. 

Fig.  58.  Definite  outline  of  the  lower  pole  of  the  right  kidney.  Over  upper  pole  is  a 
dense  shadow  which  was  reported  as  probably  a  pathological  gall-bladder.  Surgically: 
Chronic  cholecystitis.  It  was  with  great  difficulty  that  the  differential  diagnosis  between  the 
shadow  over  the  upper  pole  of  the  right  kidney  and  the  shadow  produced  by  the  upper 
pole  of  the  right  kidney  could  be  made.  The  diagnosis  from  the  roentgen  standpoint  was 
doubtful.  At  operation,  a  definite  pathological  gall-bladder  was  found. 

PLANCH E  XVIII 

Fig.  56.  Ombre  nette  dans  la  region  de  la  vesicule.  Diagnostic  radiologique:  vesicule 
probablement  malade,  hthiasc  douteuse.  A  ['operation:  vesicule  moyennement  dilatee 
remplie  de  calculs  a  base  de  bilirubine-chaux. 

Fig.  5~.  Vesicule  visible,  dans  un  cas  analogue  au  precedent.  Elle  contient  beaucoup 
de  calculs  de  bilirubinate  de  chaux  pur. 

Fig.  58.  Le  pole  inferieur  du  rem  droit,  nettement  profile.  Recouvrant  le  pole  supe- 
rieur,  unc  ombre  intense  qu'on  signala  comme  etant  probablement  la  vesicule.  A  ['opera- 
tion: cholecystite.  On  eut  beaucoup  de  mal  a  differencier  I'ombre  du  pole  superieur  d'avec 
1'ombre  sus-jaeente.  Le  diagnostic  radiologique  etait  hesitant.  A  I'operation  on  trouva  une 
vesicule  evidemment  malade. 

PLANCH  A  XVIII 

Fig.  56.  Sombra  precisa  en  la  region  biliar.  Diagnostico  roentgenologico:  probable 
colecistitis  cronica,  con  o  sin  calculos.  A  la  operacion:  vesicula  medianamente  dilatada 
Ilena  de  calculos  de  bilirubinate  de  cal. 

Fig.  j~.  Vesicula  visible  en  un  caso  analogo  al  precedente,  conteniendo  gran  numero 
de  calculus  de  bilirubinate  de  cal  puro. 

Fig.  58.  Contorno  preciso  del  polo  inferior  del  rinun  derecho.  Sobre  el  polo  superior 
se  nota  una  sombra  densa  que  se  creyo  pertenecer  a  una  vesicula  enferma.  A  la  operacion, 
se  confirmo  la  colecistitis.  La  diferenciacion  entre  la  sombra  del  polo  superior  del  rifton  y 
la  de  la  vesicula,  superpuesta,  fue  muy  dilicil.  EI  diagnostico  roentgenologico  era  dudoso. 
La  intervencion  descubrio  una  vesicula  evidentemente  enferma. 


PLAT!    Will 


Fig.   56. 


Fig.  5-. 


Fig.  58. 


PLATE  XIX 


PLANCHE  XIX 


PLANCHA  XIX 


PLATE  XIX 

Fig.  5Q.  Two  distinct  shadows,  one  due  to  the  gall-bladder  (A),  the  other,  the  lower 
pole  of  kidney  (B).  The  gall-bladder  contained  a  large  number  of  pure  bilirubin  lime  stones. 

Fig.  60.  Pathological  gall-bladder,  apparently  without  stones,  and  pressure  on  an- 
trum of  stomach.  Surgically:  Chronic  cholecystitis. 

Fig.  6i.     Pathological  gall-bladder  containing  small  stones. 

Fig.  62.  Visible  gall-bladder  in  a  woman.  Surgically:  Chronic  cholecystitis,  with  one 
stone  in  the  common  duct,  which  was  not  visible  on  examination.  This  examination  was 
made  at  the  twenty-four-hour  period. 

PLANCHE  XIX 

Fig.  59.  Deux  ombres  bien  defmies;  I'une,  A,  due  a  la  vesicule;  1'autre,  B,  au  pole 
inferieur  du  rein.  La  vesicule  contenait  de  nombreux  calculs  de  bilirubinate  de  chaux. 

Fig.  60.  Meme  malade.  On  voit  ici  la  pression  exercce  par  la  vesicule  Mir  la  premiere 
portion  du  duodenum. 

Fig.  61.     Vesicule  malade  contenant  des  petits  calculs. 

Fig.  62.  Vesicule  visible  chez  une  femme.  A  ('operation:  cholecystite  chronique, 
avec  un  calcul  dans  le  canal  choledoque.  II  etait  demeure  invisible  a  la  radiographic 

PLANCHA  XIX 

Fig.  ,().  Dos  sombras  bien  definidas:  una  (A)  es  la  de  la  vesicula  y  la  otra  (B)  del 
polo  inferior  del  rinon.  La  vesicula  contenia  numerosos  calculos  de  bilirubinato  de  cal  puro. 

Fig.  60.  Vesicula  enferma,  aparentemente  sin  calculos,  pero  comprimiendo  el  antro 
pilorico.  A  la  operacion,  colecistitis  cronica. 

Fig.  61.     Vesicula  enferma  conteniendo  calculos  pequenos. 

Fig.  62.  Vesicula  visible  en  una  mujer.  A  la  operacion;  colecistitis  cronica  con  un 
calculo  en  el  coledoco  que  no  se  revelo  durante  el  examen.  Este  examen  se  hizo  24.  horas 
despues  de  mgendo  el  desayuno  opaco. 


I'l   VI  I     \l\ 


Fig.   ,-< 


Fig.  60. 


Fig.  61. 


I  ....  62. 


PLATE  XX 


PLANCHE  XX 


PLANCHA 


PLATE  XX 

Fig.  63.  Definite  pathological  gall-bladder  with  no  evidence  of  stones.  (See  Fig.  64 
for  surgical  findings.) 

Fig.  64.  Gall-bladder  after  removal,  showing  the  gall-bladder,  before  opening,  to 
contain  one  large  stone.  Note  in  this  instance  that  the  periphery  of  the  stone  shows  no 
calcium  deposit.  Nucleus  of  stone  faintly  visible;  extreme  thickness  of  gall-bladder  wall. 
Roentgen  diagnosis:  Pathological  gall-bladder.  Surgically:  One  large  gall-stone  was  found. 

Fig.  65.  Plate  made  several  days  after  the  gastro-intestinal  examination  lor  confirma- 
tion of  a  shadow  found  in  the  previous  gall-bladder  plates.  Original  plates  showed  a  definite, 
visible  gall-bladder.  Surgically:  Chronic  cholecystitis  without  stones. 

Fig.  66.  Large,  dense  gall-bladder  and  several  stones.  It  is  interesting  that  in  this 
case,  throughout  the  examination,  stones  would  appear  and  disappear;  in  some  plates 
there  were  several;  in  others,  only  one.  At  operation  a  large  gall-bladder  full  of  inspissated 
bile  and  pus  was  found,  with  a  number  of  dense  calcium  stones. 

PLANCHE  XX 

Fig.  63.  Vesicule  visible,  sans  calcul  apparent.  Voir  plus  loin  pour  Ies  constatation 
operatoires. 

Fig.  64.  La  vesicule  extraitc,  avant  d'etre  ouverte.  Elle  contient  un  gros  calcul. 
Noter  qu'il  n'y  a  pas  de  calcium  dans  Ies  couches  exterieures.  Le  noyau  est  faible  mentvisible. 
Les  parois  de  la  vesicule  sont  tres  epaisses.  Diagnostic  radiologique:  vesicule  malade. 
Constatations  operatoires:  calculs. 

Fig.  65.  Cliche  fait  plusieurs  jours  apres  un  exsmen  gastro-intestinal  dans  le  but  de 
retrouver  des  ombres  nettement  percues  sur  les  radiographies  consacrees  specialement  a  la 
vesicule. 

Fig.  66.  Grosse  vesicule  tres  dense,  contenant  plusieurs  calculs.  Fait  curieux,  1'aspect 
a  varie  d'un  cliche  a  ['autre.  Certaines  plaques  montraient  plusieurs  calculs,  d'autres  un 
seul.  A  1'opcration:  grosse  vesicule  remplie  de  bile  epaissie  et  de  pus,  avec  plusieurs  calculs 
a  forte  teneur  en  chaux. 

PLANCHA  XX 

Fig.  63.  Vesicul  1  evidentemente  enferma  y  visible,  sin  calculo  aparente  (Vease  la 
fig.  64  para  las  observaciones  quirurgicas) . 

Fig.  64.  La  vesicula  extirpada  deja  ver,  antes  de  abrirla,  un  calculo  grande — Notese 
que  la  periferia  no  contiene  sales  de  calcio.  EI  nucleo  es  Iigeramente  visible.  Las  paredes  de 
la  vesicula  son  muv  gruesas.  Diagnostico  roentgenoiogico:  Colecistitis  cronica.  Obscrvacion 
quirurgica:  un  calculo  voluminoso. 

Fig.  65.  Roentgenograma  hecho  algunos  dias  despues  de  un  examen  gastro-intes- 
tinal, para  confirmar  la  preseneia  de  una  sombra  encontrada  en  anteriores  examenes  par- 
ticulares  de  la  vesicula.  Las  placas  originales  mostraban  distintamente  la  vesicula  biliar, 
La  operacion  descubrio  una  colecistitis  cronica  no  calculosa. 

Fig.  66.  Vesicula  grande  y  de  paredes  gruesas  conteniendo  varias  piedras.  Es  intere- 
sante  advertir  que  durante  el  examen  de  este  caso  Ios  calculosserevelaron  inconstantemente 
visibles;  mientras  que  algunos  clises  exhiben  varios,  otros  no  muestran  mas  que  uno.  A  la 
operacion  se  eucontro  una  vesicula  grande  Ilena  de  bilis  espesa  y  pus,  conteniendo  muchos 
ealculos  ricos  en  calcio. 


II    Ml     \\ 


Fig.  64. 


Fig.  63. 


Fig.  65. 


Fig.  66. 


PLATE  XXI 


PLANCIII    XXI 


PLANCHA  XXI 


PLATE  XXI 

Fig.  67.  Large  gall-bladder  high  up  in  the  right  quadrant,  which  could  not  be  confused 
in  the  original  plates  with  the  kidney.  Very  dense.  At  operation,  it  was  found  to  contain 
some  very  small  bilirubin  lime  stones,  but  density  in  plates  was  due  to  the  extreme  densitj 
of  the  bile  and  to  the  partial  obstruction  of  the  cystic  duct. 

Fig.  68.  Definite,  visible  gall-bladder  with  some  secondary  manifestations  in  the 
gastro-intestinal  examination — enough  to  confirm  the  opinion  that  this  shadow  represented 
the  gall-bladder.  Surgically:  Chronic  cholecystitis  without  stones. 

Fig.  69.     Pathological  gall-bladder  with  small  stones. 

Fig.  70.     Pathological  gall-bladder  without  stones. 

PLANCHE  XXI 

Fig.  67.  Grosse  vesicule  haut  situee  dans  I'hypochondre  droit.  Impossible  a  confondre 
avec  le  rein.  A  l'operation  on  y  trouva  de  tres  petits  calculs  de  bilirubinate  de  chaux,  mais 
I'opacite  etait  surtout  due  a  la  consistance  epaisse  de  la  bile  et  a  une  obstruction  du  canal 
cystique. 

Fig.  68.  Ombre  definie  pouvant  etre  la  vesicule.  Confirmation  suffisante  par  les 
symptomes  secondaires  constates  au  cours  de  1'examen  gastro-intestinal.  A  ['operation: 
cholecystite  ehronique,  sans  calculs. 

Fig.  69.     Vesicule  visible.  Elle  est  malade. 

Fig.  70.     Vesicule  malade,  sans  calculs. 

PLANCHA  XXI 

Fig.  67.  Vesicula  grande  en  la  region  mas  alta  del  hipocondrio  derecho,  imposible  de 
confundir  con  el  rifion.  Imagen  muy  densa.  A  la  operacion  contenia  algunos  calculos  peque- 
nos  de  bilirubinato  de  cal;  la  opacidad  era  debida  a  la  consistencia  espesa  de  la  bilis  y  a  una 
obstruccion  parcial  del  conducto  cistico. 

Fig.  68.  Vesicula  biliar  bien  visible.  Los  sintomas  secundarios  revelados  por  el  exa- 
men  gastro-intestinal  corroboran  esta  opinion.  A  la  operacion,  colecistitis  cronica  no 
calculosa. 

Fig.  69.     Vesicula  enferma  con  pequenos  calculus. 

Fig.  ~o.     Vesicula  enferraa  sin  calculos. 


I'l   Ml     \\l 


Fig.  67. 


Fig.  68. 


Fig.  69. 


Fig.  "ii. 


PLATE  XXII 


PLANCHE  XXII 


PLANCHA  XXII 


PLATE  XXII 

Fig.  71.  Large  pathological  gall-bladder  which  is  displacing  the  ascending  colon  and 
hepatic  flexure,  due  to  hydrops  of  the  gall-bladder. 

Fig.  72.  Shadow  of  a  large  gall-bladder.  The  position  of  the  second  portion  of  the 
duodenum  is  significant  as  suggesting  fixation.  Surgically:  Hydrops  of  the  gall-bladder. 
This  plate  was  made  in  191 3;  it  was  confirmed  at  operation  several  years  later. 

Fig.  73.  Woman,  aged  sixty.  Referred  as  a  palpable  tumor  in  the  upper  right  quad- 
rant. Clinical  diagnosis:  Probable  carcinoma  of  the  stomach.  X-ray  examination  ol  the 
stomach,  negative.  This  plate,  made  at  six  hours,  outlined  a  large  gall-bladder.  Surgically: 
Hydrops  of  the  gall-bladder.  This  shadow  was  not  determined  in  the  routine  gall-bladder 
examination,  as  the  fundus  of  the  gall-bladder  was  below  the  area  examined. 

PLANCH E  XXII 

Fig.  71.  Epanchement  dans  la  vesicule.  Elle  deplace  le  colon  ascendant  et  1'anse 
hepatique. 

Fig.  ~2.  Image  d'une  grosse  vesicule.  La  position  de  la  seconde  portion  du  duodenum 
fait  penser  a  une  fixation.  Cliche  fait  en  1913;  plusicurs  annees  apres,  I'operation  revela 
un  epanchement  dans  la  vesicule. 

Fig.  -3.  Femme  de  60  ans.  Tumeur  palpable  dans  I'hypochondre  droit.  Diagnostic 
clinique:  cancer  probable  de  I'estomac.  L'examen  radiologique  ne  revela  aucun  signe  de 
cancer.  Sur  le  cliche  ci-ioint,  fait  6  heures  apres  ingestion  de  baryum,  la  vesicule  se  montre. 
Elle  n'avait  pas  ete  vue  dans  la  serie  pregastrique.  A  I'operation:  epanchement  dans  la 
vesicule. 

PLANCH  A  XXII 

Fig.  71.  Hidropesia  de  la  vesicula.  EI  colon  ascendente  y  la  acodadura  hepatica 
aparecen  desplazados. 

Fig.  ~2.  Imagen  de  una  vesicula  grande.  La  posicion  del  segundo  segmento  del  duo 
deno  sugiere  la  posibilidad  de  adherencias  y  fijacion.  La  placa  se  hizo  en  1913;  varios  afios 
despues  la  operacion  revelo  una  hedropesia  de  la  vesicula. 

Fig.  "3.  Mujer  de  60  anos.  Presenta  un  tumor  palpable  en  el  hipocondrio  derecho 
Diagnostico  clinico:  probable  carcinoma  gastrico.  Examen  roentgenologico  del  estomago, 
negativo.  Este  clise  fue  hecho  seis  horas  despues  de  la  comida  opaca  y  ofrece  la  imagen  de 
una  vesicula  grande;  imagen  que  no  pudo  observarse  durante  el  examen  particular  de  la 
vesicula,  porque  su  fondo  descendia  por  debajo  del  area  examinada.  A  la  operacion,  hidro- 
pesia de  la  vesicula. 


PLATE  XXI] 


Fig.  71. 


Fig.  72. 


I   [G.    73. 


PI    Ml    Will 


PLANCHE  XXIII 


PLANCH  A  XXIII 


PLATE  XXIII 

Fig.  -4.  Large  pathological  gall-bladder,  very  easy  to  visualize  under  proper  tech- 
nique. Unfortunatelj  in  this  series  of  plates  we  were  unable  to  determine  the  exact  position 
of  the  kidney.  The  question  whether  this  was  the  kidney  or  not  was  difficult  to  decide. 
There  were  no  other  changes,  either  direct  or  secondary,  that  were  of  help  in  determining 
this  problem.  Clinically,  there  was  an  easily  palpable  gall-bladder;  surgically,  the  gall- 
bladder removed  was  approximately  the  size  of  the  shadow.  The  surgeon  doubted  whether 
the  shadow  found  in  the  x-ray  platewas  the  gall-bladder.  Thewriters  are  of  the  opinion  that 
this  shadow  represented  the  gall-bladder. 

Fig.  75.  Large  shadow  which  might  be  confused  with  a  possible  displaced  kidney. 
Clinically,  a  palpable  tumor;  under  fluoroscopic  examination,  palpable  and  tender.  There 
are  some  changes  caused  by  the  displacement  of  the  colon  which  would  indicate  that  it  was 
the  gall-bladder.  Surgically,  the  tumor  proved  to  be  a  moderate  hydrops  of  the  gall-bladder. 

PLANCH E  XXIII 

Fig.  74.  Grosse  vesicule  malade,  facile  a  mettre  en  evidence  avec  une  technique 
appropriee.  Malheureusement,  on  ne  put  determiner  la  position  du  rein  sur  aucun  des 
cliches  de  la  serie.  Rein  ou  vesicule?  La  reponse  n'etait  pas  facile,  aucun  symptome  indirect 
n'etayant  le  diagnostic.  Au  palper  on  sentait  la  vesicule.  A  I'operation,  celle  qui  fut  extraite 
avait  a-peu-pres  les  dimensions  de  1'ombre  figuree.  Bien  que  le  chirurgien  fut  de  1'avis  con- 
traire,  nous  croyons  avoir  montre  la  vesicule. 

Fig.  75.  Cette  ombre  etendue  pourrait  faire  croire  a  un  rein  deplace.  Elle  representait 
une  masse  palpable,  douloureuse  a  la  pression.  On  I'attribua  a  la  vesicule,  a  cause  d'un 
displacement  particulicr  du  colon.  L'operation  montra  un  epanchement  dans  la  vesicule. 

PLANCH  A  XXIII 

Fig.  -4.  Vesicula  grande  enferma,  facil  de  demostrar  con  una  tecnica  correcta 
Desgraciadamente  en  ninguna  de  las  placas  pudimos  precisar  la  situacion  del  rinon.  Era 
dilicil  decidir  si  se  trataba  del  rinon  o  de  la  vesicula,  pues  faltaban  signos  indirectos  o 
secundarios  que  habrian  ayudado  el  diagnostico.  Clinicamente,  sin  embargo,  habia  una 
vesicula  lacilmente  palpable.  La  operacion  descubrio  y  extirpo  una  vesicula  de  tamafio 
aproximado  al  de  la  sombra  del  clise.  Aunque  el  cirujano  dudo  de  que  dicha  sombra  fuera 
la  imagen  de  la  vesicula,  nosotros  creimos  que  si  lo  era. 

Fig.  "5.  Sombra  extensa  facil  de  confundir  con  un  rinon  flotante.  Clinicamente  era 
un  tumor  palpable;  al  examen  fluoroscopico,  masa  palpable  y  sensible.  En  vista  del  desplaza- 
miento  evidente  del  colon,  se  atribuyo  la  sombra  a  la  vesicula  biliar.  La  intervencion  qui- 
rurgica  probo  que  el  tumor  era  la  vesicula  hedropica. 


I 'I  \l  I    win 


Fig. 


Fig.   75. 


PLATE  XXIV 


PLANCHE  XXIV 


PLANCHA  XXIV 


PLATE  XXIV 

Fig.  76.  Definite  pathological  gall-bladder,  easily  visible  by  the  plate  or  film  method. 
This  patient  had  been  examined  by  the  fluoroscopic  method;  no  evidence  of  a  pathological 
gall-bladder.  Confirmed  at  operation. 

Fig.  77.  Visible  gall-bladder,  moderate  in  size,  fixed  to  the  hepatic  flexure.  Plate 
shows  a  picking  up  of  the  colon  by  adhesions.  Surgically:  Chronic  cholecystitis,  with  adhe- 
sions. 

Fig.  78.  Large  bowel  full  of  barium  b\  the  enema  method;  visible  gall-bladder,  which 
had  been  confirmed  by  a  series  of  gall-bladder  plates,  and  was  proved  pathological  at 
operation. 

Fig.  79.     Outline  of  a  pathological  gall-bladder  overlying  the  shadow  of  the  kidney. 

PLANCH E  XXIV 

Fig.  76.  Une  vesicule  bien  definie,  facile  a  radiographier  sur  plaques  ou  films.  Une 
radioscopie  n'avait  rien  montre  de  suspect. 

Fig.  77.  Vesicule  de  moyenne  taille,  fixee  a  I'anse  hepatique.  On  voit  que  Ie  colon  est 
tiraille  par  des  adherences.  A  I'operation:  cholecystite  chronique,  avec  adherences. 

Fig.  78.  Colon  rempli  de  baryum  par  voie  rectale.  La  vesicule  biliaire  est  visible, 
corame  d'ailleurs  sur  les  plaques  consacrees  specialement  a.  sa  recherche.  Elle  etait  malade. 

Fig.  79.     Profil  d'une  vesicule  malade  recouvrant  celui  du  rein. 

PLANCHA  XXIV 

Fig.  76.  Vesicula  evidentemente  enferma,  de  facil  demostracion  roentgenografica. 
EI  examen  fluoroscopico,  sin  embargo,  fue  ncgativo.  Confirmacion  quirurgica. 

Fig.  77.  Vesicula  de  tamano  moderado  fijada  a  la  acodadura  hepatica  del  colon.  EI 
disc  muestra  como  las  adherencias  agarran  el  colon.  Comprobacion  quirurgica:  colecistitis 
cronica  adhesiva. 

Fig.  ~8.  Colon  Ileno  con  1111  enema  opaco.  Vesicula  visible,  segun  habia  demostrado 
ya  otra  serie  de  placas.  A  la  operacion,  colecistitis  cronica. 

Fig.  79.     Imagen  de  la  vesicula  biliar  enferma  sobrepuesta  a  la  sombra  del  rinon. 


I'l  ATI.  \.\l\ 


i 


r 


Fig.  76. 


Fig.  — 


Fig.  78. 


Fig.  79. 


THE  PATHOLOGICAL  GALL-BLADDER:  INDIRECT 

EVIDENCE 

1  he  changes  thai  take  place  in  the  first  portion  of  the  duodenumand 
the  second  portion  <>l  the  duodenum  have  proved  to  be  oi  definite  importance 
in  the  diagnosis  oi  the  pathological  gall-bladder,  [*oo  greal  importance  can- 
not be  attached  to  pressure  delects  due  to  the  gall-bladder  upon  tin-  first 
portion  oi  the  duodenum.  Although  perhaps  it  would  not  be  wise  in  everj 
instance  to  consider  pressure  defects  as  the  chiel  point  in  the  diagnosis,  ye1 
it  is  one  oi  the  important  signs  toward  making  the  diagnosis. 

Plate  XW  ,  Figures  No,  Si  and  82  are  used  to  show  the  normal  stom- 
ach, and  the  first,  second)  and  third  portions  ol  the  duodenum.  Figure  80  was 
proved  surgically  to  be  normal.  I  his  is  the  absolute  normal  so  far  as  the  rela- 
tions ol  the  parts  ol  the  stomach  and  duodenum  are  concerned.  Figures  Si 
and  82  show  the  extreme  variations  ol  the  normal  second  portion  ol  the  duo- 
denum. Changes  found  in  Figure  81  may,  under  certain  conditions,  be  con- 
sidered abnormal,  orjJicse  changes  may  be  due  to  adhesions  from  the  gall- 
bladder, yet  one  meets  with  such  changes,  especially  in  an  individual  who  is 
poorly  nourished  and  has  marked  ptosis  of  the  abdominal  organs.  In  the 
absence  ol  other  direct  or  indirect  evidence,  one  must  be  cautious  in  laying 
too  much  stress  on  changes  similar  to  those  found  111  Figure  81. 

Plate  XXVI  strikingly  illustrates  pressure  defects  due  to  the  gall-bladder 
on  the  first  portion  of  the  duodenum,  fixation  and  deformity,  and  change  in 
the  position  ol  the  second  portion  ol  the  duodenum  due  to  ,1  pathological 
condition  of  the  biliary  tract. 

LA  INDICES  INDIRECTS  DES  AFFECTIONS  VESI- 
CULATES 

Les  modifications  qui  peuvent  survenir  dans  la  premiere  e1  la  seconde 
portion  du  duodenum  ne  sunt  pas  a  dedaigner  pour  le  diagnostic  des  affec- 


138  PATHOLOGICAL  GALL-BLADDERS 

tions  vesiculates.  II  est  impossible  d'exagerer  la  signification  des  deforma- 
tions que  la  vesicule  peute  imprimer.  Sans  doute  il  serait  temeraire  de 
dormer  a  ce  signe  la  premiere  place,  mais  il  reste  tres  important. 

Dans  la  Planehe  XXV,  figures  80,  81  et  82,  servent  a  montrer  I'esto- 
mac  et  Ies  trois  portions  du  duodenum.  La  norme  absolue  se  trouve  dans  la  fig- 
ure 80.  Elle  a  ete  verifiee  chirurgicalement.  Les  figures  81  et  82  montrent 
des  variations  considerables  de  la  seconde  portion  du  duodenum;  elles  n'ont 
aucune  signification  pathologique.  Les  changements  figures  dans  la  figure  81 
peuvent  etre  attribuables  a  des  adherences  avec  la  vesicule.  Ne  pas  oublier, 
toutefois,  qu'on  pent  les  trouver  chez  des  individus  a  nutrition  defectueuse 
et  sujets  aux  ptoses.  En  I'absence  de  symptomes  corroboratifs,  on  se  gardera 
done  d'v  attacher  trop  d'importance  (fig.  81). 

La  planehe  XXVI  demontre  clairement  I'effet  des  compressions  de 
la  vesicule  sur  la  premiere  portion  du  duodenum,  les  tiraillements,  deplace- 
ments  et  autres  deformations  de  la  seconde  portion  a  la  suite  d'un  etat 
pathologique  des  voies  biliaires. 

SIGNOS  INDIRECTOS  (DE  COLECISTITIS) 

Las  modificaciones  cjue  pueden  sobrevenir  en  Ios  dos  primeros  segmentos 
del  duodeno  son  realmente  utiles  para  el  diagnostico  de  las  colecistitis. 
Aunque  no  debe  de  concederse  una  importancia  excesiva  a  las  deformaciones 
que  la  presion  de  la  vesicula  ocasiona  a  veces  sobre  la  porcion  bulbar  del 
duodeno,  es  sin  embargo  un  excelente  sintoma,  pero  no  el  mas  importante 
de  todos. 

Las  figuras  80,  81  y  82  delaplancha  XXV  sirven  paramostrarelestomago 
normal  y  Ios  tres  segmentos  del  duodeno.  La  figura  80  corresponde  a  un  caso 
absolutamente  normal,  comprobado  quirurgicamente,  en  cuanto  a  las  rela- 
ciones  mutuas  entre  las  diversas  partes  del  estomago  y  del  duodeno.  Las 
figuras  81  y  82  ensenan  variaciones  considerables  en  la  segunda  porcion  del 


I'l   VI  I     \\\ 


Fig.  80. 


Fig.  8i. 


Fig.  82. 


PLATH  XXVI 


PLANCHE  XXVI 


PLANCIIA  XXVI 


PLATE  XXVI 

Lateral  view  shows  definite  pressure  defect  upon  the  first  portion  of  the  duodenum 
due  to  a  pathological  gall-bladder.  In  the  original  plates  certain  shadows  suggested  the 
possibility  of  gall-stones.  We  also  found  the  ampulla  of  Vater  filled  throughout  the  series. 
At  operation  no  fixation  of  the  gall-bladder  to  the  duodenum  was  found.  Several  gall- 
stones. Definite  thickening  of  the  gall-bladder  walls. 

PLANCH  E  XXVI 

La  vue  Iaterale  revele  une  deformation  tres  nette  de  la  premiere  portion  du  duodenum 
par  la  vesicule  malade.  Dans  les  cliches  originaux,  certaines  ombres  faisaient  penser  a  des 
calculs.  A  travers  toule  la  serie  nous  trouvames  I' ampoule  de  Vater  remplie  de  baryum. 
A  1'  operation,  la  vesicule  ne  se  montra  pas  adherente  au  duodenum.  Iy  y  avait  plusieurs 
calculs  et  un  epaississement  certain  des  parois  de  la  vesicule. 

iPLANCHA  XXVI j 

La  vista  lateral  muestra  claramente  la  presion  de  la  vesicula  sobre  la  primera  porcion 
del  duodeno.  En  las  placar  originales  crertas  sombras  hicieronso  spechar  la  presencia  de 
calculos  biliares.  La  ampolla  de  Vater  aparecio  llena  da  bario  eu  todos  los  clises  de  la  serie. 
La  operacion  descubrio  una  vesicula  de  paredes  espesas,  conteniendo  algunos  calculos. 
No  habia  adherencias  al  duodeno. 


r.EORC.E  if  LEONARD-  GAI  I    I'-LAPP!  R 


PLATE  XXVI 


ROENTGEN    ILOGY, 


.  :•  M;  .■  in 
I    B    HOEB1  k.  s 


PATHOLOGICAL  GALL-BLADDERS  143 

duodeno  c|iu'  no  son,  sin  embargo,  patologicas.  Las  alteraciones  descubiertas 
en  la  figura  Si  podrian,  bajo ciertas  circunstancias,  considerarse  anormales  0 
ser  atribuidas  a  adherencias  con  la  vesicula,  pero  tambien  pueden  encontrarse 
en  sujetos  normales  pobremente  nutridos  \  afectos  <le  ptosis  de  lasvisceraf 
abdominales.  Asi  pueSj  en  la  ausencia  clc  otros  signos  directos  <>  indirectos, 
no  sera   prudente  conceder  demasiada    importancia  a  dichas  alteraciones 

(fig.  80- 

Los  clises  de  la  plancha  \\\  I  (demuestran)  con  toda  claridad  el  efecto 
iU'  [as  compresiones  de  la  vesicula  sobre  la  porcion  bulbar  drl  duodeno  e  igu- 
almente  las  deformaciones,  desplazamientos  y  fijacion  anomala  de  la  segunda 
porcion,  consecutivas  a  los  estados  patologicos  de  las  vias  biliares. 


PI  ATE  XXV 1 1 


PIAXCIIP  XX\  II 


PLANCIIA  XXVII 


PLATE  XXVII 

Figs.  83  and  84  (both  illustrating  the  same  case)  and  Figs.  85  and  86  (illustrating  a 
similar  case).  Subhepatic  fixation  of  the  stomach.  This  change  from  normal  in  the  position 
of  the  stomach  and  the  duodenum  is,  in  some  instances,  the  only  indication  of  pathology 
in  the  biliary  tract,  and  such  changes  should  be  regarded  as  a  warning  to  make  a  more  care- 
ful study  of  the  gall-bladder  region  if  the  examination  previously  made  has  seemed  negative. 
Errors  may  arise  even  in  apparently  well-fixed  positions  of  the  stomach  to  the  right,  so 
that  upon  operation  no  evidence  of  this  fixation  will  be  found.  But  this  is  only  one  ot  the 
minor  indirect  evidences  of  possible  pathology  in  the  gall-bladder. 

PLANCHE  XXVII 

Figs.  83  et  84.  Elles  illustrent  Ie  meme  cas.  Les  figures  85  et  86,  un  cas  analogue. 
L'estomac  est  fixe  sous  le  loie.  Cette  anomalie,  ainsi  que  Ie  displacement  du  duodenum,  peut- 
etre  Ie  seul  indice  d'un  etat  pathologique  des  voies  biliaires.  Cest  un  encouragement  a 
reprendre  les  cliches  "vesicule"  s'ils  n'ont  pas  ete  concluants.  On  peut  trouver,  a  I'operation, 
que  l'estomac  n'est  pas  tiraille  a  droite,  en  depit  des  apparences.  Mais  il  y  a  d'autres  signes 
indirects  des  affections  biliaires. 

PLANCH  A  XXVII 

Figs.  83  y  84  se  refieren  al  mismo  caso;  y  la  85  y  86  a  otro  analogo.  Fijacion  infra- 
hepatica  del  estomago.  Esta  situacion  anomala  del  estomago  y  duodeno  es,  en  algunos 
casos,  el  unico  indicio  del  estado  patologico  de  las  vias  biliares;  v  debe  deconsiderarsecomo 
un  estimulo  para  repctir  cuidadosamente  el  examen  de  la  region  vesicular,  si  las  primeras 
investigaciones  fueren  negativas.  Puede  ocurrir  tambien  que  la  intervencion  quirurgica,  a 
despecho  de  las  apariencias  roentgenograficas,  no  encuentre  el  estomago  desviado  a  la  de- 
recha  ni  fiio;  pero  este  signo  es  uno  de  Ios  sintomas  indirectos  menos  importantes  de  las 
enfermedades  biliares. 


PLAT]    XXVII 


Fig.  83. 


Fig.  84. 


Fig.  85. 


I  i...  86. 


PLATE  XXVIII 


PLANCHK  XXVIII 


PLANCHA  XXVIII 


PLATE  XXVIII 

Fig.  87.  Pressure  of  a  moderately  dilated  pathological  gall-bladder  by  fixation  upon 
the  first  portion  of  the  duodenum  and  the  pylorus.  It  will  be  noted  that  the  pylorus  is  pulled 
toward  the  gall-bladder  area.  This  observation  was  constant  through  a  series  of  plates 
made  in  this  position.  It  changed  only  moderately  in  the  upright  position.  The  first  portion 
(if  the  duodenum  is  elongated  toward  the  liver  and  fixed. 

PLANCH E  XXVIII 

Fig.  87.  Pression  exercee  par  une  vesicule  moyennement  dilatee  sur  Ie  pylore  et  la 
portion  initiale  du  duodenum.  Le  pylore  est  ancre  a  la  region  vesiculate.  Cet  etat  de 
choses,  constant  dans  tons  les  cliches  de  la  serie  couchee,  se  modifia  tres  peu  dans  la  station 
verticale.  La  premiere  portion  du  duodenum  est  attiree  et  fixee  au  foie. 

PLANCHA  XXVIII 

Fig.  8^.  Muestra  la  presion  eiercida  por  una  vesicula  medianamente  dilatada  sobre 
el  piloro  y  la  primera  porcion  del  duodeno.  Notese  que  el  piloro  ha  sido  arrastrado  haciala 
region  vesicular.  El  primer  segmento  del  duodeno  aparece  estirado  y  adherido  al  higado. 
Esta  observacion  fue  constante  en  todas  las  placas  de  la  misma  serie  hechas  en  igual  posi- 
cion;  vario  Iigeramente  con  el  enfermo  en  la  estacion  vertical. 


I'l  \  1 1   \\\  III 


Fig.  87. 


PLATE  XXIX 


PLANCH!    \\l.\ 


PLANCHA  XXIX 


[PLATE  XXIX 

Fig.  88.  Delect  clue  to  pressure  of  gall-stones  upon  the  first  portion  of  the  duodenum 
and  fixation  of  the  beginning  of  the  second  portion  ol  the  duodenum. 

Fig.  89.  Deformity  of  the  first  portion  of  the  duodenum  with  a  pseudodiverticulum 
due  to  adhesions  from  the  gall-bladder. 

Fig.  90.  Artist's  drawing  of  the  same  case  as  is  shown  in  Fig.  89,  illustrating  changes 
found  at  operation. 

PLANCHE  XXIX 

Fig.  88.  Deformation  de  la  premiere  portion  du  duodenum  et  fixation  du  commence- 
ment de  la  seconde  par  une  vesicule  calculeuse. 

Fig.  89.  Deformation  de  la  premiere  portion  du  duodenum  et  pseudodiverticule  cause 
par  des  adherences  a  la  vesicule. 

Fig.  90.     Dessin  montrant  ce  qu'on  trouva  a  I'operation  du  malade  de  la  figure  89. 

PLANCHA  XXIX 

Fig.  88.  Deformacion  del  primer  segmento  del  duodeno  y  fijeza  de  la  porcion  inicial 
del  segundo  producidas  por  una  vesicula  calculosa. 

Fig.  89.  Deformacion  del  primer  segmento  del  duodeno  y  pseudo-diverticulo,  oca- 
sionados  por  adherencias  a  la  vesicula. 

Fig.  90.     Dibujo  mostrando  Io  que  se  encontro  en  la  operacion  del  caso  de  la  fig.  89. 


PLAT]    XXIX 


Fig.  88. 


Fig.  89. 


Omentum 


PijIoruS 


i<> 


Fig. 


on. 


PLATE  XXX 


PLANCIII    XXX 


PLANCH  A  XXX 


PLATE  XXX 

Fig.  91.  A  constant  filling  delect  of  the  first  portion  of  the  duodenum.  Clinically:  No 
evidences  of  ulcer.  Plates  are  not  characteristic  of  ulcer.  Roentgen  diagnosis:  Pathological 
gall-bladder  with  probable  gall-stones.  Surgically:  Pathological  gall-bladder  with  stones. 

Fig.  92.  Defect  of  the  first  portion  of  duodenum.  Opinion  passed  from  this  roentgen 
examination:  Chronic  ulcer  of  the  duodenum,  with  gall-stones.  At  operation,  the  deformity 
was  found  to  be  due  to  fixation  of  the  gall-bladder.  No  evidence  of  ulcer.  Gall-stones. 

PLANCHE  XXX 

Fig.  91.  Radiographic  d'un  individu  corpulent  montrant  un  defaut  persistant  de  la 
premiere  portion  du  duodenum  Pas  de  symptomes  cliniques  de  I'ulcere.  Les  cliches  non  plus 
n'etant  passuggestifs  de  I'ulcere,  on  diagnostiqua:  vesicule  malade,  probablement  calculeuse. 
Confirmc. 

Fig.  92.  Defaut  clans  la  premiere  portion  du  duodenum.  Diagnostic  radiologique: 
ulcere  chronique  du  duodenum  avec  calculs  bihaires.  A  I'operation:  calculs,  adherences 
peri-vesiculaires,  pas  d'ulcere. 

PLANCH  A  XXX 

Fig.  91.  Laguna  persistente  de  la  primera  porcion  del  duodeno.  No  hay  signos 
clinicos  de  ulcera.  Los  discs  tampoco  son  caractiristecos  de  ulcera.  Diagnostico  roent- 
genologico:  enfermedad  de  la  vesicula,  probable  colelitiasis.  Confirmacion  operatoria. 

Fig.  92.  Laguna  en  el  primer  segmento  del  duodeno.  Diagnostico  roentgenologico: 
ulcera  cronica  del  duodeno  con  calculos  biliares.  La  operacion  descubrio  calculos  y  adhe- 
encias  peri-yesiculares;  pero  no  Iesiones  uicerativas. 


P]   \M     \W 


It,.     91. 


: 


Fig.  92. 


IM    Ml    W\l 


PLANCHE  XXXI 


PLANCH  A  XXXI 


PLATE  XXXI 

Figs.  93,  94,  95  (illustrating  the  same  case).  Pressure  defect  upon  the  first  portion  of 
the  duodenum,  due  to  gall-stones.  In  this  instance,  the  gall-stones  were  not  found  in  the 
original  plates  until  after  the  operation  although  they  were  plainly  visible.  Roentgen  diagno- 
sis:  Probable  gall-bladder  disease  by  pressure  delect  in  the  first  portion  of  the  duodenum. 

PLANCHE  XXXI 

Figs.  93,  94  et  95.  Meme  malade.  Les  calculs  deforment  la  premiere  portion  du  duode- 
num, lis  ne  furent  apercus  qu'apres  ['operation,  bien  qu'iis  fussent  evidents. 

PLANCH  A  XXXI 

Figs.  93,  94  y  95.  (Se  refieren  al  mismo  caso.)  Defecto  por  compresion  de  la  vesicula 
calculosa  sobre  la  primera  porcion  del  duodeno.  Aunque  Ios  calculos  eran  netamente  visibles 
en  Ios  clises,  pasaron  sin  embargo  desapercibidos  en  su  primera  Iectura;  fue  despues  del  acto 
operatorio  que  una  revision  cuidadosa  permitio  descubrirlos.  EI  diagnostic©  roentgenologico 
habia  sido:  probable  enfermedad  de  la  vesicula,  supuesta  por  la  compresion  y  deformacion 
del  duodeno. 


I'l  \  1 1   \\\l 


Fig.  93. 


Fig.  94. 


I   IG.    95. 


pi.au.  xxxii 


PLANCHE  XXXII 


PLANCH  A  XXXII 


PLATE  XXXII 

Figs.  96  and  97  (illustrating  the  same  ease).  Visible  gall-stones  defect,  being  charac- 
teristic of  an  obstructive  chronic  ulcer  of  the  duodenum.  In  the  writers'  opinion  this  filling 
defect  of  the  duodenum  was  due  to  chronic  ulcer.  At  operation,  gall-stones  were  found  with 
perforation  of  the  gall-bladder  into  the  duodenum. 

Fig.  98.  Pressure  defect  upon  the  first  portion  of  the  duodenum,  due  to  a  gall-stone, 
which  was  not  visible  in  our  examination. 

Fig.  99.  Lateral  view  oi  same  case  as  shown  in  Fig.  98,  showing  the  same  pressure 
defect. 

PLAXCHE  XXXII 

Figs.  96  et  97.  Deformation  produite par des  calculs,  mais  simulant  un  ulcerechronique 
du  duodenum.  On  opta  pour  I'ulcere,  mais  I'operation  revela  des  calculs,  avec  fistule  vesiculo- 
duodenale. 

Fig.  98.  Deformation  par  pression  sur  la  premiere  portion  du  duodenum,  due  a  un 
calcul  qui  ne  fut  pas  decele  par  la  radiographic. 

Fig.  99.     Meme  cas,  vue  laterale  (tig.  98).  Autre  aspect  de  la  deformation. 

PLANCH  A  XXXII 

Figs.  96  y  97.  (Se  refieren  al  mismo  caso.)  Deformacion  producida  por  calculos 
biliares,  simulando  el  aspecto  caracteristico  de  una  ulcera  cronica  y  obstructiva  del  duodeno. 
En  opinion  de  Ios  autores  la  laguna  del  duodeno  se  debia  a  una  ulcera.  Laoperaciondescubrio 
calculos  biliares  con  perforacion  de  la  vesicula  dentro  del  duodeno. 

Fig.  98.  Deformacion  del  primer  segmento  del  duodeno  por  un  calculo  biliar  invisible 
durante  el  examen. 

Fie.  99.     Vista  lateral  del  mismo  caso  de  la  fig.  98,  mostrando  eldefectoporcompresion. 


'I  A  I  I     \  \  \  I 


Fig.  96. 


Fig.  97. 


In..  98. 


Fig.  99. 


H   VII    X.Will 


PI.ANCIH.  XXXIII 


H.ANCIIA  WXIII 


PLATE  XXXIII 

Fig.  ioo.  Illustrates  pressure  of  the  gall-bladder,  containing  stones,  with  adhesions 
to  the  first  portion  of  the  duodenum.  Confirmed  at  operation. 

Fig.  ioi.  Pressure  of  a  gall-bladder  against  the  first  portion  of  the  duodenum.  This 
plate  is  republished  here  to  illustrate  the  type  of  pressure  that  the  writers  feel  is  important 
as  at  least  suggestive  of  the  pathological  gall-bladder,  which  might  or  might  not  contain 
gall-stones. 

Fig.  102.  Lateral  view  of  a  stomach  showing  pressure  of  the  gall-bladder  upon  the 
first  portion  of  the  duodenum,  and  a  visible,  single  large  gall-stone.  This  stone  was  not 
visible  in  the  routine  gall-bladder  examination. 

Fig.  103.  Extreme  pressure  of  a  large  gall-bladder  with  fixation  of  the  stomach  to 
the  gall-bladder.  No  stones  found. 

PLAXCHE  XXXIII 

Fig.  ioo.  Pression  exercee  par  une  vesicule  calculeuse  adherente  a  la  premiere  portion 
du  duodenum.  Confirmation  operatoire. 

Fig.  ioi.  Vesicule  deformant  la  premiere  portion  du  duodenum.  Nous  pensons  qu'une 
telle  deformation  est  pour  Ie  moins  tres  suggestive  d'un  etat  pathologique  de  la  vesicule,  avec 
ou  sans  calculs. 

Fig.  102.  Gros  calcul  decouvert  au  cours  de  I'examen  gastrique  et  demeure  invisible 
dans  la  serie  pregastrique.  On  voit  la  pression  exercee  sur  la  premiere  portion  du  duodenum. 

Fig.  103.  Deformation  considerable  et  fixation  de  I'estomac  a  la  vesicule.  Pas  de 
calculs. 

PLANCHA  XXXIII 

Fig.  ioo.  Compresion  de  una  vesicula  calculosa  adherida  a  la  primera  porcion  del 
duodeno;  conlirmada  quirurgicamente. 

Fig.  ioi.  Compresion  de  la  vesicula  sobre  el  primer  segmento  del  duodeno.  Este 
clise  se  reproduce  con  el  fin  de  mostrar  el  tipo  de  deformacion  que  los  autores  consideran 
sugestivo  de  estados  patologicos  de  la  vesicula,  acompaflados  o  no  de  calculos. 

Fig.  102.  Vista  lateral  del  estomago  mostrando  la  presion  de  la  vesicula  sobre  el 
primer  segmento  del  duodeno.  Vese  tambien  un  calculo  solitario  grande.  Esta  piedra  paso 
inadvertida  en  el  examen  regular  de  las  vias  biliares. 

Fig.  103.  Deformacion  considerable  y  fijacion  del  estomago  a  una  vesicula  volumi 
nosa.  Ausencia  de  calculos. 


I'l  \l  I    XXXII] 


Fig.   too. 


Fig.   mi . 


Fig.   102. 


Fig.   103. 


PLATE  \\\l\ 


PLANCHEX\\I\ 


PLANCII\  XXXIV 


PLATE  XXXIV 

Fig.    104.     Fixation  of  first  portion  of  the  duodenum  to  a  pathological  gall-bladder. 

Fig.  105.  Illustrates  the  direct,  the  indirect,  and  the  secondary  manifestations  of 
pathology  in  the  biliary  tract.  It  is  to  be  noted  that  the  jejunum  is  transferred  from  its 
normal  position  on  the  left  to  the  upper  right  quadrant.  There  is  a  marked  deformity  of  the 
first  portion  of  the  duodenum,  suggestive  of  ulcer,  found  to  be  due  to  adhesions,  for  the  most 
part.  The  pathological  gall-bladder  is  found  in  the  original  plates. 

Fig.  106.  Gall-bladder  of  case  illustrated  in  Fig.  10^  after  removal,  before  being 
opened.  Full  of  stones  of  such  character  that  they  will  not  in  themselves  cast  a  shadow.  It 
is  to  be  noted  that  the  contained  bile  is  denser  in  character  than  the  gall-stones  themselves. 

PLANCHE  XXXIV 

Fig.    104.     La  portion  initiale  du  duodenum  est  ancree  a  un  ve.sie.ule  malade. 

Fig.  105.  Illustrant  Ies  signes  directs,  indirects  et  secondaires  des  etats  pathologiques 
de  la  vesicule.  Noter  que  Ie  jejunum,  au  lieu  d'etre  a  gauche  comme  d'habitude,  est  dans 
I'hypochondre  droit.  Deformation  considerable  de  la  premiere  portion  du  duodenum  sug- 
gerant  un  ulcere,  mais  due  en  majeure  partie  a  des  adherences.  Sur  Ie  cliche  original  on  voit 
la  vesicule  malade. 

Fig.  106.  La  vesicule  du  cas  precedent  (fig.  105),  extirpee,  mais  pas  encore  ouverte. 
A  cause  de  leur  composition,  les  calculs  qui  s'y  trouvent  ne  portent  pas  d'ombre  appreciable. 
Noter  que  la  bile  est  plus  opaque  que  Ies  calculs. 

PLANCHA  XXXIV 

Fig.    104.     Primera  porcion  del  duodeno  adherida  y  lija  a  la  vesicula  enferma. 

Fig.  105.  Demuestra  los  signos  directos,  indirectos  y  secundarios  de  Ios  procesos 
patologicos  biliares.  Notese  que  el  yeyuno  ha  sido  traspuesto  al  hipocondrio  derecho.  Hay 
notable  deformacion  del  primer  segmento  del  duodeno,  como  en  las  ulceras,  pero  en  este 
caso  producida  mayormente  por  adherencias.  Sobre  Ios  clises  originales  se  nota  la  vesicula 
enferma. 

Fig.  106.  Vesicula  del  caso  anterior  despues  de  extirpada,  pero  sin  abrir.  Llena  de 
calculos  de  composicion  quimica  tal  que  no  pueden  proyectar  sombra  apreciable.  La  bilis 
es  mas  opaca  que  Ios  calculos. 


>LA1  I    XXXIV 


Fig.   104 


Fig.   105. 


Fig.   Hid. 


PLATE  XXX\ 


PLANCIII    WW 


PLANCUA  XXXV 


PLATE  XXXV 

Fig.  107.  Adhesions  due  to  the  pathological  gall-bladder  and  chronic  ulcer  of  the 
duodenum. 

Fig.  108.  Artist's  drawing  of  case  shown  in  Fig.  107,  illustrating  the  changes  found 
in  this  type  of  case. 

PLANCHE  XXXV 

Fig.  107.  Adherene.es  eonsecutives  a  une  affection  biliaire;  ulcere  chronique  du  duo- 
denum. 

Fig.   108.     Dessin  figurant  ee  qu'on  trouve  dans  des  cas  comme  celui  de  la  fig.  107. 

PLANCHA  XXXV 

Fig.   107.     Adherencias  consecutivas  a  una  afeccion  biliar  y  ulceracronicadelduodeno. 
Fig.    108.     Dibujo  figurando  lo'que  se  encontro  en  el  caso  de  ia  fig.  107. 


Ml     WW 


t 


I   lc.     107. 


V 


Ulcer. 


.V- 


bf' 


* 


A*V 


I  i < ; .    10S. 


H  All    WW  I 


PLANCIII    WW  I 


PLANCIIA  WW  I 


PLATE  XXXVI 

Plates  XXXVI  and  XXXVII  illustrate  a  very  important  sign  which,  when  present,  is 
indicative  oi  the  pressure  of  a  moderately  dilated  or  distended  and  thickened  gall-bladder,  or 
a  gall-bladder  full  of  stones  that  rests  against  the  antrum  of  the  stomach.  This  change  is  so 
characteristic,  when  found,  that  to  the  writers  it  becomes  one  of  the  most  important  indirect 
signs. 

Fig.  109.  Pressure  defect  of  the  pathological  gall-bladder  upon  the  antrum  of  the 
stomach.  Confirmed  at  operation. 

Fig.  1 10.  Pressure  defect  upon  the  antrum  of  the  stomach.  In  the  original  plates  it 
was  thought  possible  to  see  small  shadows  within  this  area  which  indicated  small  stones. 
At  operation,  the  pathological  gall-bladder  and  several  very  small  stones  were  found. 

PLANCH E  XXXVI 

Les  plauches  xxxvi  et  xxxvii  illustrent  un  signe  tres  precieux  qui  origine  de  la  pression 
d'une  vesicule  moderement  dilatee  ou  epaissie  011  calculeuse  sur  I'antre  pylonque  en  contact 
avec  elle.  Ce  signe  a  une  importance  que  nous  estimons  capitale. 

Fig.  109.  Pression  exercee  par  une  vesicule  malade  sur  I'antre  pylonque.  Verifie  a 
l'operation. 

Fig.  1 10.  Deformation  du  pylore  par  pression  exteneure.  On  crut  apercevoir,  dans  Ie 
voisinage,  deux  petites  ombres  suspectes.  A  l'operation:  vesicule  malade  contenant  plusieurs 
tres  petits  calculs. 

PLANCHA  XXXVI 

Los  roentgenogramas  de  las  planchas  xxx\  1  y  xxxvii  ilustran  un  signo  muy  importante, 
efecto  de  la  presion  de  una  vesicula  moderadamente  dilatada  o  de  paredes  gruesas  y  dis- 
tendida  orepleta  de  calculos,  apoyandose  contra  el  antro  pilorico.  Es  una  alteracion  pato- 
Iogica  tan  caracteristica  que  los  autores  la  considcran  como  uno  de  Ios  signos  indirectos 
mas  importantes. 

Fig.  109.  Laguna  del  antro  pilorico  causada  por  presion  de  la  vesicula  enferma.  Con- 
firmacion  opcratoria. 

Fig.  iio.  Deformacion  del  antro  pilorico  por  presion  de  la  vesicula.  Se  creyo  poder 
distinguir  en  Ios  primeros  clises  pequeiias  sombras  de  origen  calculoso  dentro  de  la  zona 
lacunar.  La  operacion  descubrio  una  vesicula  enferma  conteniendo  varios  calculos  muy 
pequenos. 


I'l   \l  I     \V\VI 


Fig.   i 


PLATE  XXXVII 


PLANCIII".  XXXVII 


PI  ANCHA  XXXVI] 


PLATE  XXXVII 

Fig.  hi.  Fixation  by  adhesions  of  the  first  portion  of  the  duodenum  and  antrum  of 
the  stomach  to  the  gall-bladder  area.  Pressure  delect  upon  the  antrum  of  the  stomach  due 
to  the  gall-bladder.  Stones  visible. 

Fig.  112.  Pressure  defect  upon  the  antrum  of  the  stomach,  due  to  the  pathological 
gall-bladder  without  stones. 

PLANCH  E  XXXVII 

Fig.  iii.  Tiraillement  de  I'antre  pylorique  et  du  duodenum  vers  la  region  vesiculate. 
Encoche  de  compression  a  I'antre.  Calculs  visibles. 

Fig.   112.     Deformation  de  I'antre  pylorique  par  une  vesicule  malade  non-calculeuse. 

PLANCH  A  XXXVII 

Fig.  iii.  EI  antro  pilorico  y  la  primera  porcion  del  duodeno  aparecen  fijos  por  ad- 
herencias  a  la  region  vesicular.  La  presion  de  la  vesicula  causa  una  Iaguna  del  antro  pilorico. 
Calculos  visibles. 

Fig.   112.     Deformacion  del  antro  pilorico  por  vesicula  enferma  no  calculosa. 


PI   Ml     WW  II 


'IG.    III. 


Fig.   112. 


PLATE  WW  III 


PLWCIII    WW  III 


PLANCHA  WW  III 


PLATE  XXXVIII 

Fig.  113.  Pressure  of  the  pathological  gall-bladder  against  the  antrum  of  the  stomach, 
also  displacement  of  the  first  portion  of  the  duodenum. 

Fig.  114.  Pathological  gall-bladder  causing  pressure  against  and  displacement  of 
the  first  portion  of  the  duodenum  and  a  part  of  the  antrum  of  the  stomach. 

Fig.  115.  Pathological  gall-bladder.  (Plate  made  in  six  hours.)  No  visible  gall-stones 
found  during  gall-bladder  examination.  Stomach  fixed  to  the  subhepatic  region  without  any 
other  indirect  or  secondary  manifestations.  During  six-hour  examination,  plates  showed  this 
fixation  with  a  group  of  gall-stones.  Plate  used,  in  this  instance,  to  illustrate  the  pressure  of 
the  gall-bladder  against  the  antrum  of  the  stomach. 

PLANCH E  XXXVIII 

Fig.  113.  Compression  exercee  par  une  vesicule  malade  sur  1'antre  pylorique  et 
emplacement  de  la  premiere  portion  du  duodenum. 

Fig.   114.     Cas  analogue  au  precedent. 

Fig.  1 15.  Vesicule  malade.  On  n'avait  pas  trouve  de  calculs  sur  Ies  cliches  consacres 
a  Ieur  recherche;  on  en  trouva  sur  la  plaque  des  6  heures.  L'estomac  est  ancre  sous  le  foie  et 
son  pylore  est  deforme. 

PLANCHA  XXXVIII 

Fig.  113.  Presion  de  la  vesicula  enferma  sobre  el  antro  pilorico  y  desplazamiento  de 
la  primera  porcion  del  duodeno. 

Fig.  114.  Vejiga  biliar  patologica  comprimiendo  y  desplazando  la  primera  porcion 
del  duddeno  y  parte  del  antro  pilorico. 

Fig.  115.  Vesicula  enferma  (placa  de  seis  horas).  El  examen  roentgenologico especial 
de  las  vias  biliares  no  demostro  calculos.  Estomagofijadoalaregioninfra-hepatica.  Ausencia 
de  otros  signos  indirectos.  Ademas  de  la  fijaeion,  la  placa  de  seis  horas  muestra  un  grupode 
calculos.  Notese  la  presion  de  la  vesicula  sobre  el  antro  pilorico. 


I'l   Ml     WW  III 


I'  !(,.      II 


Fig.  114. 


Fig.   1 1  5. 


PLA1  I    KXXIX 


PLANCHE  XXXIX 


PLANCIIA  XXXIX 


PLATE  XXXIX 

Fig.  i  1 6.  Definite  fixation  of  the  second  portion  of  the  duodenum  to  the  gall-bladder. 
In  the  gall-bladder  plates  particles  of  calcium  were  found  within  the  gall-bladder  area.  In 
this  plate,  we  see  faintly  the  calcium  shadow  within  the  area  of  the  gall-bladder. 

Fig.  i  17.  Artist's  drawing  of  the  case  shown  in  Fig.  1 16,  made  at  the  time  of  opera- 
tion. Positive  fixation  of  the  second  portion  of  the  duodenum  to  the  gall-bladder;  the 
calcium  shadows  found  in  the  original  plates  were  due  to  gall-stones. 

Fig.  118.  Fixation  of  the  second  portion  of  the  duodenum  to  the  gall-bladder.  At 
operation,  a  small  number  of  very  small  bilirubin  lime  stones  were  found.  A,  shows  faint 
outline  of  the  gall-bladder. 

PLANCHE  XXXIX 

Fig.  1 16.  Fixation  evidente  de  la  deuxieme  portion  du  duodenum  a  la  vesicule.  Dans 
Ies  cliches  de  la  serie  "vesicule"  on  trouva  des  taches  calcaires  correspondant  a  son  emplace- 
ment. On  voit  ici  une  ombre  assez  faible  situee  clans  Ies  limites  du  profil  de  la  vesicule. 

Fig.  ii~.  Dessin  fait  au  cours  de  I'operation  du  cas  precedent  (fig.  1 16).  Les  consta- 
tations  de  la  radiologic  sont  confirmees. 

Fig.  118.  Fixation  de  la  deuxieme  portion  du  duodenum  a  la  vesicule.  En  A  on 
voit  la  vesicule  faiblement  dessinee.  A  I'operation:  quelques  petits  calculs  de  bilirubinate  de 
calcium. 

PLANCH  A  XXXIX 

Fig.  116.  Fijacion  evidente  de  la  segunda  porcion  del  duodeno  a  la  vesicula.  Tanto 
en  los  clises  de  la  serie  especial  de  la  vesicula  como  en  este  se  ven  sombras  calcareas  en  la 
zona  vesicular. 

Fig.  ii".  Dibujo  del  mismo  caso  hecho  durante  la  operacion.  Confirma  la  fijacion 
del  duodeno  y  la  presencia  de  calculos. 

Fig.  118.  Fijacion  a  la  vesicula  de  la  segunda  porcion  del  duodeno.  La  operacion 
descubre  un  pequeno  numero  de  diminutos  calculos  de  bilirubinate  de  cal.  (A)  sehala  el 
delicado  contorno  vesicular. 


IM  \l  I    XXXIX 


Lii/cr 


Duo 


Vom 


Fig.   i  [6. 


Fig.   ti" 


PLATE   XL 


PLANCHE  \l 


PLANCHA  XL 


PLATE  XL 

Fig.  119.  Pressure  defect  by  the  gall-bladder  upon  the  second  portion  of  the  duo- 
denum in  a  woman,  aged  eighteen.  Gall-bladder  contained  a  large  number  of  very  small 
calcium  bilirubin  stones. 

Fig.  120.  Deformity  of  the  second  portion  ol  the  duodenum  due  to  adhesions. 
Origin  of  the  adhesions  was  not  fully  determined  at  operation. 

PLANCH E  XL 

Fig.  119.  Pression  exercee  par  la  vesicule  sur  la  deuxieme  portion  du  duodenum 
chez  une  femme  de  18  ans.  On  trouva  un  grand  nombre  de  tres  petits  calculs  de  bilirubinate 
de  chaux. 

Fig.  120.  Defaut  dans  la  deuxieme  portion  du  duodenum,  du  a  des  adherences  dont 
on  ne  put  determiner  la  cause  a  1'operation. 

PLANCHA  XL 

Fig.  119.  Compresion  de  la  vesicula  sobre  el  segundo  segmento  del  duodeno  en  una 
joven  de  18  aiios.  La  vesicula  contenia  gran  numero  de  diminutos  calculos  de  bilirubinate 
decal. 

Fig.  120.  Deformacion  del  segundo  segmento  del  duodeno,  causadaporadherencias — 
La  operacion  no  preciso  el  origen  de  dichas  adherencias. 


I'l   Ml     XL 


Fig.  i  21 


PLATE  Ml 


PLANCHE  XL! 


PI.WCIIA  \l  I 


PLATE  XLI 

Figures  121,  122,  123  and  124  illustrate  the  filling  of  the  ampulla  of  Vater  during 
the  barium  meal.  It  has  been  found,  in  the  writers'  experience,  that  with  all  other  signs 
absent,  when  the  ampulla  of  Vater  is  found  lull  of  barium  during  the  meal,  it  is  signifi- 
cant of  pathological  changes  in  the  biliary  tract  or  within  the  pancreas.  This  sign  should 
not  be  considered  a  positive  indication  of  disease  either  of  the  biliary  tract  or  of  the 
pancreas,  but  more  as  a  warning  that  something  has  been  overlooked  in  the  previous 
gall-bladder  examination.  One  should  persist  in  these  cases  in  looking  for  direct  or  indirect 
evidence  of  pathology  either  of  the  biliary  tract  or  of  the  pancreas.  The  errors  that  may  arise 
in  this  connection  are  in  occasional  cases  where  a  small  diverticulum  of  the  second  portion 
of  the  duodenum  or  an  ulcer  with  perforation  may  simulate  a  barium-filled  ampulla. 

Fig.   123.     Collection  of  gall-stones  and  the  ampulla  of  Vater  filled  with  barium. 

Fig.  124.  Barium-filled  ampulla  in  the  right  lateral  diameter  (A);  pressure  of  a 
moderately  dilated  gall-bladder  upon  the  second  portion  of  the  duodenum  (B).  These  two 
observations  together  make  a  reasonably  positive  diagnosis. 

PLANCHE  XLI 

Les  figures  121,  122,  123  et  124  illustrent  la  penetration  du  repas  baryte  dans  I' ampoule 
de  Vater.  Dans  I'experience  des  auteurs,  quand  tous  les  autres  signes  manqueraient,  la 
presence  du  baryum  dans  ['ampoule  denote  un  etat  pathologique  de  la  vesicule  011  du 
pancreas.  II  n'y  faudrait  pas  voir  un  signe  patho  gnomonique,  mais  un  avertissement 
d'avoir  a  scruter  plus  attentivement  les  radiographics  deja  prises  de  la  vesicule.  Rechercher 
avec  persistance  les  signes  de  morbidile  dans  les  voies  bihaires  011  Ie  pancreas.  II  est  bon 
de  se  rappeler  qu'un  petit  diverticule  dans  la  seconde  portion  du  duodenum  ou  un  ulcere 
perforant  pourraient  dormer  le  change  et  simuler  une  ampoule  remplie  de  baryum. 

Fig.    123.     Amas  de  calculs.  Ampoule  de  Vater  remplie  de  baryum. 

FiG.  124.  A,  I'ampoule  vue  en  position  laterale  droite.  B,  pression  par  une 
vesicule  movennement  dilatee  sur  la  seconde  portion  du  duodenum.  On  peut  etre  assez 
affirmatif  quand  on  a  les  deux  signes. 

PLANCHA  XLI 

Los  siguientes  roentgenogram  as  (figs.  121,  122,  123  y  124)  ilustran  la  penetracion  de  la 
comida  opaca  en  la  ampolla  de  Vater.  Es  la  creencia  de  Ios  autores  que,  en  la  ausencia  de 
otros  sintomas,  esta  penetracion  es  signo  probable  de  un  estado  morboso  de  las  vias  biliares 
o  del  pancreas.  No  es  un  sintoma  de  certeza,  sino  mas  bien  una  sefial  de  alerta  de  que  algo 
paso  desapercibido  durante  los  examenes  previos  y  de  que  es  necesario  persistir  en  la  in- 
vestigacion  de  Ios  signos  directos  o  indirectos  de  las  afecciones  biliares  o  pancreaticas.  No 
se  olvide,  sin  embargo,  que  un  pequeno  diverticulo  de  la  segunda  porcion  del  duodeno  o 
una  ulcera  perforante  pueden  simular  la  ampolla  de  Vater  Ilena  de  bario. 

Fig.    123.     Coleccion  de  calculos  y  ampolla  de  Vater  Ilena  de  bario. 

Fig.  124.  (A)  la  ampolla  de  Vater,  Ilena  de  bario,  vista  en  pocicion  lateral  derecha. 
(B)  Segunda  porcion  del  duodeno  comprimida  por  una  vesicula  moderadamente  dilatada. 
Con  estos  dos  signos  puede  aventurarse  un  diagnostico  positivo. 


I'l  \  II    \l 


Fig.   i2i. 


Fig.   122. 


Fig.  123. 


Fig.   i  2 1. 


PLATE  XI  M 


PLANCH  I    XI  M 


PLANCHA  XI  II 


PLATE  XLII 

Fig.  125.  Jejunum  transferred  from  the  left  to  the  right  upper  quadrant.  This  change 
is  significant  of  one  of  two  things:  it  is  due  either  to  adhesions  in  the  upper  right  quadrant 
or  to  changes  which  are  the  result  of  tubercular  peritonitis  in  early  life.  Occasionally,  tumors 
in  the  upper  left  quadrant,  such  as  hypernephroma  of  the  kidney  or  a  markedly  enlarged 
spleen,  will  displace  the  jejunum  to  the  right.  This  can  be  determined  by  pressure  on  the 
stomach,  which  will  be  produced  by  a  hypernephroma  or  an  enlarged  spleen. 

Fig.  126.  Postoperative  effect  upon  the  stomach  causing  marked  deformity — the  re- 
sult of  cholecystotomy.  The  original  plates  showed  2  remaining  gall-stones.  These  are  not 
visible  m  the  reproduction. 

Fig.  i2~.  Secondary  manifestations  of  probable  gall-bladder  disease  upon  the  hepatic 
flexure  and  the  proximal  portion  of  the  transverse  colon.  These  changes  were  confirmed  at 
operation.  Similar  changes  occur  commonly  in  very  large  and  well-nourished  individuals, 
when  gall-bladder  disease  is  present;  uncommonly  in  those  very  poorly  nourished. 

PLANCHE  XLII 

Fig.  125.  De  gauche,  le  jejunum  a  passe  dans  1'hypochondre  droit.  Cela  peut  etre 
du  a  des  adherences  dans  cette  region  ou  a  des  modifications  produites  au  cours  du  jeune 
age  par  une  peritonite  tuberculeuse.  Parfois,  des  tumeurs  dans  1'hypochondre  gauche,  com- 
me  l'h\  pernephrome  ou  I'hypertrophie  de  la  rate,  peuvent  produire  le  meme  effet.  Mais  alors, 
on  a  des  deformations  considerables  de  I'estomac. 

Fig.  126.  Deformation  considerable  de  I'estomac  consecutive  a  une  cholecystotomie. 
Les  cliches  originaux  montrent  deux  calculs  oublies.  On  ne  peut  les  voir  ici. 

Fig.  i2~.  Contrecoup  d'une  affection  probable  de  la  vesicule  sur  la  coudure  hepatique 
et  la  portion  initiale  du  transverse.  Verifie  a  1'operation.  Cet  etat  de  choses  est  frequent  chez 
les  malades  corpulents,  rare  chez  les  amaigris. 

PLANCHA  XLII 

Fig.  125.  Yeyuno  trasportado  desde  la  izquierda  al  hipocondrio  derecho.  Esta  modi- 
ficacion  patologica  puede  ser  ocasionada,  ora  por  adherencias  en  la  region  biliar  o  bien  por 
lesiones  consecutivas  a  una  peritonitis  tuberculosa  de  la  infancia.  A  veces  Ios  tumores  del 
hipocondrio  izquierdo,  como  el  hipernefroma  o  las  esplenomegahas,  desplazan  el  yeyuno 
hacia  la  derecha,  pero  entonces  coexisten  deformaciones  considerables  del  estomago. 

Fig.  126.  Notable  deformacion  del  estomago  consecutiva  a  una  colecistotomia.  Los 
discs  originales  muestran  dos  calculos  olvidados  por  el  cirujano.  No  se  ven  en  esta  copia. 

Fig.  12-.  1  fecto  secundario  de  una  afeccion  probable  de  la  vesicula  biliar  sobre  la 
acodadura  hepatica  del  colon  y  la  porcion  inicial  del  transverso,  confirmado  por  la  operacion. 
Alteraciones  analogas  son  Irecuentes  en  los  enfermos  corpulentos  y  robustos;  raras  en  los 
flacos. 


I'l   VI  I     \1  II 


III,.    12*' 


Fig.  127. 


PLA1 I    \l  Ml 


I'l   WCIII-  XI. Ill 


PLANCH  A  XLIII 


PLATE  XLIII 

Fig.  128.  The  more  common  type  of  deformity  of  the  hepatic  flexure  and  proximal 
portion  of  the  transverse  colon  due  to  adhesions  in  the  upper  right  quadrant,  both  from 
the  gall-bladder  and  from  veils  and  adhesions  of  this  portion  of  the  bowel.  These  changes 
become  more  important  when  there  is  distinct,  direct  evidence  of  pathology  in  the  biliary 
tract. 

Fig.  129.  Type  of  spasm  which  has  been  found  frequently  associated  with  gall-bladder 
disease.  This  spasm  involves  the  antrum  of  the  stomach,  producing  a  tubular  appearance 
in  the  distal  end  of  the  stomach  for  a  distance  of  several  inches.  It  is  interesting  to  note 
when  found  with  evidence  of  gall-stones  or  other  pathology  of  the  biliary  tract,  though  in 
itself  it  is  not  an  important  diagnostic  sign. 

PLANCHE  XLIII 

Fig.  128.  Aspect  habitue!  des  deformations  de  1'anse  hepatique  et  de  la  portion  initi- 
ale  du  colon  transverse  par  suite  d'adherences  dans  i'hypoehondre  droit.  Elles  peuvent 
avoir  une  origine  vesiculate  ou  intestinale.  Quand  on  aura,  par  ailleurs,  des  signes  d'affection 
biliaire,  ces  deformations  sont  tres  significatives. 

Fig.  129.  Type  de  spasme  gastrique  irequemment  associe  a  l'existence  des  affections 
de  la  vesicule.  II  etreint  tout  I'antre  pylorique  et  peut  le  reduire  a  I'etat  d'un  simple  tube 
sur  une  longueur  de  plusieurs  centimetres.  Isolement,  ce  signe  n'a  pas  grande  importance. 

PLANCHA  XLIII 

Fig.  128.  Variedad  la  mas  comun  de  las  deformaciones  de  la  acodadura  hepatica  del 
colon  y  porcion  inicial  del  transverso,  producidas  por  adherencias  en  el  hipocondrio  derecho, 
ya  provengan  de  la  vesicula  o  se  deban  a  franjas  membranosas  o  adherencias  intestinales. 
Cuando  coexisten  con  signos  directos  de  enfermedad  biliar,  estas  deformaciones  son  muy 
significativas. 

Fig.  129.  Variedad  de  espasmo  gastrico  frecuentemente  asociado  a  Ios  procesos 
vesiculares;  comprime  el  antro  pilorico  y  Io  transforma  en  un  tubo  sobre  una  extension  de 
varios  centimetros.  Importante  cuando  coincide  con  otros  signos  de  enfermedad  biliar,  no 
tiene  por  si  solo  gran  valor  diagnostico. 


I'l   VII     Mil 


Fig.   129. 


PLATE  XI  IV 


PLANCHE  XLIV 


PLANCHA  XLIV 


PLATE  XLIV 

Figs.  130,  131,  132  (the  same  case).  Clinically  diagnosed  as  gall-stones.  The  roent- 
gen examination  revealed  a  group  ot  gall-stones  as  seen  in  Fig.  1 30.  Stones  the  size  of  gall- 
stones, and  with  most  of  their  usual  characteristics,  were  found  as  clearly  defined  on  the 
kidney  examination  as  on  the  gall-bladder  examination.  The  lateral  view  (Fig.  131)  showed 
the  stones  in  the  anatomical  region  of  the  kidney.  The  writers  felt  that  unless  there  was 
some  very  unusual  anatomical  rearrangement  of  the  gall-bladder,  kidney,  and  stomach, 
these  shadows,  for  the  most  part  at  least,  must  be  within  the  kidney.  For  various  reasons  it 
was  impossible  to  cystoscope  this  case  and  iniect  the  kidneys.  In  spite  of  the  tacts  obtained 
by  this  examination  and  the  probability  that  these  were,  in  the  most  part,  stones  within 
the  kidney,  the  case  w-as  operated  upon  as  a  case  of  gall-stones.  No  evidence  whatsoever 
of  pathology  was  found  within  the  gall-bladder.  The  kidney  was  explored  and  removed. 
Fig.  132  shows  the  kidney  with  these  stones  within  the  kidney  substance.  This  case  and  the 
series  of  plates  illustrate  the  value  of  the  right  lateral  view  in  determining  whether  or  not  a 
suspected  stone  or  stones  are  located  in  the  normal  position  for  the  gall-bladder  or  kidney. 
In  a  large  percentage  of  cases,  the  lateral  view  will  determine  whether  the  shadows  are  of 
the  gall-bladder  or  its  contents,  or  whether  they  are  ol  the  kidney. 

PLANCHE  XLIV 

Figs.  130,  131,  132.  Meme  cas.  Diagnostic  chnique:  lithiasc  biliaire.  La  radio- 
graphic (Fig.  130),  montra  des  calculs.  La  radiographic  du  rem  en  montra  d'analogues. 
Un  cliche  en  position  Iaterale  (fig.  131),  fit  voir  qu'ils  siegeaient  dans  la  Ioge  renale.  On  dut 
conclure  qu'a  moins  d'anomalie  anatomique,  ces  ombres,  pour  la  plupart,  devaient  etre 
dans  Ie  rein.  Pour  diverses  raisons  on  ne  put  faire  une  pyelographie.  En  depit  des  constata- 
tions,  on  decida  d'explorer  la  vesicule.  Elle  eta  it  absolumcnt  normale.  On  enleva  le  rein;  la 
figure  132  Ie  montre  avec  sun  contenu.  Tout  ceci  prouve  I'utilite  de  la  vue  en  Iaterale  droite 
quand  il  s'agit  de  rapporter  des  calculs  au  rem  droit  ou  a  la  vesicule  biliaire. 

PLANCHA  XLIV 

Figs.  130,  131  y  132.  Se  refieren  al  mismo  caso.  Diagnostico  clinico;  colelitiasis. 
Los  roentgenogramas  de  la  vesicula  (fig.  130)  revelaron  un  grupo  de  calculos  de  tamafio  y 
cstructura  semejantes  a  Ios  biliares.  Los  roentgenogramas  del  riii6n  tambien  revelaron  cal- 
culos similares.  La  radiografia  lateral,  sin  embargo  (fig.  131),  mostraba  Ios  calculos  en  la 
region  renal.  Se  opino  que,  salvo  alguna  anomalia  anatomica,  las  sombras,  cuando  menos  en 
su  mayor  parte,  eran  de  origen  renal.  Por  circunstancias  especiales  no  se  hizo  una  pielografia. 
A  pesar  de  Ios  signos  en  contrario,  se  decidio  explorar  las  vias  biliares,  que  resultaron  com- 
pletamente  normales.  Entonces  se  practico  la  nefrectomea  derecha.  La  ligura  132  muestra 
la  imagen  de  dicho  rinon  conteniendo  Ios  calculos  denunciados  por  Ios  anteriores  roentgeno- 
gramas. Hechos  semejantes  prueban  la  capital  importancia  de  la  radiogralia  en  posicion 
lateral  derecha  para  diferenciar  Ios  calculos  biliares  de  Ios  renales.  En  una  gran  proporcion 
de  casos  ella  decidira  si  las  sombras  son  de  la  vesicula  o  si  contenido,  osi  proceden  del  rinon. 


I'l    \  I  I     \l  !\ 


Fig.   130. 


Fig.  131. 


Fig.  13: 


Date  Due 

PRINTED   IN    O.S.A 


CAT     NO     24    161 


D  000  225  511  5 


WI  750 
G3U?p 
1922 
George,  Arial  W 

The  pathological  gall-bladder 


Jeorge,  Arial  W 
The  pathological  gall-bladder 


WI  75C 

G3^7d 

1922 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


